MEDICARE: OCEAN ISLE BEACH FAMILY MEDICINE. PC

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	261QP2300X	Primary Care Clinic/Center	181477	NC

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	B502	OTHER	NC	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	1902162928	OTHER	NPI
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	34D1040435	OTHER	CLIA

General Provider Information

NPI Number	:	1902162928
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OCEAN ISLE BEACH FAMILY MEDICINE. PC

Provider Business Mailing Address
First Line	:	120 CAUSEWAY DR STE 3
Second Line	:
City	:	OCEAN ISLE BEACH
State	:	NC
Zip	:	28469-7581
Country	:	US
Telephone Number	:	910-575-5004
Fax Number	:	855-575-0700

Provider Business Practice Location Address
First Line	:	120 CAUSEWAY DR STE 3
Second Line	:
City	:	OCEAN ISLE BEACH
State	:	NC
Zip	:	28469-7581
Country	:	US
Telephone Number	:	910-575-5004
Fax Number	:	855-575-0700

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	DR. DANIEL R. BLIZZARD
Credential	:	DO
Telephone Number	:	910-575-5004

Provider Enumeration Date	:	04/03/2012
Last Update Date	:	10/25/2017

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