Healthcare Provider Details

I. General information

NPI: 1548582596
Provider Name (Legal Business Name): EAST CAROLINA NEUROLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2010
Last Update Date: 02/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2280 HEMBY LN
GREENVILLE NC
27834-3773
US

IV. Provider business mailing address

2280 HEMBY LN
GREENVILLE NC
27834-3773
US

V. Phone/Fax

Practice location:
  • Phone: 252-752-4848
  • Fax: 252-752-9607
Mailing address:
  • Phone: 252-752-4848
  • Fax: 252-752-9607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number2646
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number1188
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1188
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2646
License Number StateNC

VIII. Authorized Official

Name: ROBIN B AVERY
Title or Position: ADMINISTRATIVE ASSISTANT
Credential:
Phone: 252-752-4848