Healthcare Provider Details

I. General information

NPI: 1457469165
Provider Name (Legal Business Name): BLADEN MEDICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 08/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 E MCKAY ST SUITE A
ELIZABETHTOWN NC
28337-0517
US

IV. Provider business mailing address

PO BOX 517
ELIZABETHTOWN NC
28337-0517
US

V. Phone/Fax

Practice location:
  • Phone: 910-862-5500
  • Fax: 910-862-2107
Mailing address:
  • Phone: 910-862-5500
  • Fax: 910-862-2107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number29651
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number22998
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number200101455
License Number StateNC

VIII. Authorized Official

Name: MRS. DONNA L BOWEN
Title or Position: ADMINISTRATIVE ASSISTANT
Credential:
Phone: 910-862-5500