Healthcare Provider Details

I. General information

NPI: 1982797072
Provider Name (Legal Business Name): FAYETTEVILLE PULMONOLOGY CRITICAL CARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 01/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1205 CAPE CT SUITE A
FAYETTEVILLE NC
28304-4404
US

IV. Provider business mailing address

1205 CAPE CT SUITE A
FAYETTEVILLE NC
28304-4404
US

V. Phone/Fax

Practice location:
  • Phone: 910-678-8611
  • Fax: 910-678-8100
Mailing address:
  • Phone: 910-678-8611
  • Fax: 910-678-8100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number95-01525
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number95-01525
License Number StateNC

VIII. Authorized Official

Name: GAUTAM DEV
Title or Position: MEDICAL DOCTOR PRESIDENT
Credential: MD
Phone: 910-678-8611