Healthcare Provider Details

I. General information

NPI: 1255397725
Provider Name (Legal Business Name): CAPE FEAR REGIONAL UROLOGICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 01/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1537 OWEN PARK LN
FAYETTEVILLE NC
28304-3454
US

IV. Provider business mailing address

1537 OWEN PARK LN
FAYETTEVILLE NC
28304-3454
US

V. Phone/Fax

Practice location:
  • Phone: 910-485-8801
  • Fax: 910-485-5605
Mailing address:
  • Phone: 910-485-8801
  • Fax: 910-485-5605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number9400496
License Number StateNC

VIII. Authorized Official

Name: SUSAN WILSON
Title or Position: OFFICE MANAGER
Credential:
Phone: 910-485-8801