Healthcare Provider Details

I. General information

NPI: 1205865979
Provider Name (Legal Business Name): EDGEWATER MEDICAL CENTER AND URGENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 11/09/2023
Certification Date: 11/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 S 10TH STREET
LILLINGTON NC
27546-6690
US

IV. Provider business mailing address

100 S 10TH STREET
LILLINGTON NC
27546-6690
US

V. Phone/Fax

Practice location:
  • Phone: 910-893-4111
  • Fax: 910-893-9850
Mailing address:
  • Phone: 910-893-4111
  • Fax: 910-893-9850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. RODOLFO C REYES
Title or Position: OWNER/MANAGER
Credential: M.D.
Phone: 910-893-4111