Healthcare Provider Details

I. General information

NPI: 1114987476
Provider Name (Legal Business Name): NORTHEAST ORTHOPEDICS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 12/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

354 COPPERFIELD BLVD, NE
CONCORD NC
28025-2402
US

IV. Provider business mailing address

PO BOX 1606
CONCORD NC
28026-6002
US

V. Phone/Fax

Practice location:
  • Phone: 704-788-3155
  • Fax: 704-785-8302
Mailing address:
  • Phone: 704-788-3155
  • Fax: 704-785-8302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: BRUCE WILLIAM THOMPSON
Title or Position: ADMINISTRATOR
Credential: MA MBA
Phone: 704-788-3155