Healthcare Provider Details

I. General information

NPI: 1134460892
Provider Name (Legal Business Name): OBXMD, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2013
Last Update Date: 03/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4721 N CROATAN HWY
KITTY HAWK NC
27949-8912
US

IV. Provider business mailing address

4721 N CROATAN HWY
KITTY HAWK NC
27949-8912
US

V. Phone/Fax

Practice location:
  • Phone: 252-256-7792
  • Fax: 252-256-7691
Mailing address:
  • Phone: 252-256-7792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number2005-01853
License Number StateNC

VIII. Authorized Official

Name: KAREN A SUPAN-MCPHERSON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 252-256-7792