Healthcare Provider Details

I. General information

NPI: 1588805188
Provider Name (Legal Business Name): CID PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2009
Last Update Date: 07/16/2020
Certification Date: 07/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1774 METROMEDICAL DRIVE
FAYETTEVILLE NC
28304-3861
US

IV. Provider business mailing address

1774 METROMEDICAL DRIVE
FAYETTEVILLE NC
28304-3861
US

V. Phone/Fax

Practice location:
  • Phone: 910-568-3903
  • Fax: 910-568-3908
Mailing address:
  • Phone: 910-568-3903
  • Fax: 910-568-3908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: KRISTINA MARIE RONNFELDT
Title or Position: PRACTICE MANAGER
Credential:
Phone: 910-568-3903