Healthcare Provider Details

I. General information

NPI: 1710942610
Provider Name (Legal Business Name): FARMVILLE INTERNAL MEDICINE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 04/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3485 N MAIN ST
FARMVILLE NC
27828-1466
US

IV. Provider business mailing address

3485 N MAIN ST
FARMVILLE NC
27828-1466
US

V. Phone/Fax

Practice location:
  • Phone: 252-753-3193
  • Fax: 252-753-7966
Mailing address:
  • Phone: 252-753-3193
  • Fax: 252-753-7966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number200000090
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20000090
License Number StateNC

VIII. Authorized Official

Name: DR. RICARDO ENRIQUE MARANA
Title or Position: PRESIDENT
Credential: MD
Phone: 252-753-3193