Provider Demographics
NPI:1992764211
Name:SHALLOTTE MEDICAL CENTER INC
Entity type:Organization
Organization Name:SHALLOTTE MEDICAL CENTER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BERNARD
Authorized Official - Middle Name:LEROY
Authorized Official - Last Name:LANGSTON
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:910-754-8731
Mailing Address - Street 1:PO BOX 409
Mailing Address - Street 2:BOLIVIA MEDICAL CENTER
Mailing Address - City:BOLIVIA
Mailing Address - State:NC
Mailing Address - Zip Code:28422
Mailing Address - Country:US
Mailing Address - Phone:910-253-7990
Mailing Address - Fax:910-253-8028
Practice Address - Street 1:3875 BUSINESS HWY 17 E
Practice Address - Street 2:
Practice Address - City:BOLIVIA
Practice Address - State:NC
Practice Address - Zip Code:28422
Practice Address - Country:US
Practice Address - Phone:910-253-7990
Practice Address - Fax:910-253-7990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-23
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC343928AMedicaid
NC343928AMedicaid
NC343928Medicare Oscar/Certification