MEDICARE: ECSU STUDENT HEALTH SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QS1000X	Student Health Clinic/Center

General Provider Information

NPI Number	:	1083056287
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ECSU STUDENT HEALTH SERVICES

Provider Business Mailing Address
First Line	:	1704 WEEKSVILLE RD
Second Line	:
City	:	ELIZABETH CITY
State	:	NC
Zip	:	27909-7977
Country	:	US
Telephone Number	:	252-335-3267
Fax Number	:	252-335-3269

Provider Business Practice Location Address
First Line	:	1704 WEEKSVILLE RD
Second Line	:
City	:	ELIZABETH CITY
State	:	NC
Zip	:	27909-7977
Country	:	US
Telephone Number	:	252-335-3267
Fax Number	:	252-335-3269

Authorized Official
Title or Position	:	DIRECTOR
Name	:	REGINA MCCOY-DAVIS
Credential	:	RN, MSN
Telephone Number	:	252-335-3267

Provider Enumeration Date	:	07/29/2013
Last Update Date	:	07/29/2013

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