MEDICARE: APPALACHIAN STATE UNIVERSITY

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	252Y00000X	Early Intervention Provider Agency
2	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility		NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1730240714
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	APPALACHIAN STATE UNIVERSITY

Provider Business Mailing Address
First Line	:	203 AVERY AVE
Second Line	:
City	:	MORGANTON
State	:	NC
Zip	:	28655-3102
Country	:	US
Telephone Number	:	828-433-7176
Fax Number	:	828-437-8329

Provider Business Practice Location Address
First Line	:	203 AVERY AVE
Second Line	:
City	:	MORGANTON
State	:	NC
Zip	:	28655-3102
Country	:	US
Telephone Number	:	828-433-7176
Fax Number	:	828-437-8329

Authorized Official
Title or Position	:	INTERIM DIRECTOR
Name	:	MRS. PATRICE WHITE
Credential	:	BA
Telephone Number	:	828-433-7176

Provider Enumeration Date	:	12/13/2006
Last Update Date	:	06/03/2008

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1346467008 — MR. ROBERT WAYNE KLEIN FNP-BC
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Directions to “APPALACHIAN STATE UNIVERSITY ” Practice Location

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