Healthcare Provider Details

I. General information

NPI: 1962434324
Provider Name (Legal Business Name): PINEHURST SURGICAL CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 10/05/2023
Certification Date: 10/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 FIRST VILLAGE DRIVE
PINEHURST NC
28374
US

IV. Provider business mailing address

PO BOX 2000
PINEHURST NC
28374-2000
US

V. Phone/Fax

Practice location:
  • Phone: 910-295-6831
  • Fax: 910-295-0244
Mailing address:
  • Phone: 910-295-6831
  • Fax: 910-295-0244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: CHARLES GREGG
Title or Position: CEO
Credential:
Phone: 910-295-6831