Healthcare Provider Details

I. General information

NPI: 1639462880
Provider Name (Legal Business Name): ALBEMARLE HOSPITAL FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2011
Last Update Date: 05/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 TARPON TRL
JACKSONVILLE NC
28546-5287
US

IV. Provider business mailing address

PO BOX 1412
ELIZABETH CITY NC
27906-1412
US

V. Phone/Fax

Practice location:
  • Phone: 910-938-1114
  • Fax: 910-938-1118
Mailing address:
  • Phone: 252-475-0033
  • Fax: 252-384-4051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number200200418
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number97995
License Number StateNC

VIII. Authorized Official

Name: RAYMOND C OWINGS
Title or Position: CFO
Credential:
Phone: 252-384-4168