MEDICARE: CALABASH PRIMARY CARE LLC

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	363A00000X	Physician Assistant	27331	NC
2	363L00000X	Nurse Practitioner	201575	NC
3	207Q00000X	Family Medicine Physician	27938	NC

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	203024	OTHER	NC	MEDICARE
2	DB2289	OTHER	NC	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	10048	OTHER	NC	BLUE CROSS & BLUE SHIELD
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1528139987
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CALABASH PRIMARY CARE LLC

Provider Business Mailing Address
First Line	:	10195 BEACH DR SW # 5
Second Line	:
City	:	CALABASH
State	:	NC
Zip	:	28467-2701
Country	:	US
Telephone Number	:	910-575-6538
Fax Number	:	910-575-6541

Provider Business Practice Location Address
First Line	:	10195 BEACH DR SW # 5
Second Line	:
City	:	CALABASH
State	:	NC
Zip	:	28467-2701
Country	:	US
Telephone Number	:	910-575-6538
Fax Number	:	910-575-6541

Authorized Official
Title or Position	:	OWNER
Name	:	CATHY SELLERS SR.
Credential	:	NURSE PRACTICIONER
Telephone Number	:	910-575-6538

Provider Enumeration Date	:	11/10/2006
Last Update Date	:	06/04/2009

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Directions to “CALABASH PRIMARY CARE LLC ” Practice Location

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