Healthcare Provider Details

I. General information

NPI: 1639381973
Provider Name (Legal Business Name): ADMA PRIMARY CARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2007
Last Update Date: 10/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 PEMBERTON HILL RD STE 102
APEX NC
27502-4265
US

IV. Provider business mailing address

1001 PEMBERTON HILL RD STE 102
APEX NC
27502-4265
US

V. Phone/Fax

Practice location:
  • Phone: 919-362-1836
  • Fax:
Mailing address:
  • Phone: 919-362-1836
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number9901025
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier891208Q
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name: DR. SHOBANA SENTHILNATHAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 919-362-1836