Healthcare Provider Details

I. General information

NPI: 1700889557
Provider Name (Legal Business Name): PINEHURST NEPHROLOGY ASSOCIATES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 09/16/2025
Certification Date: 09/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

293 OLMSTED BLVD STE 7
PINEHURST NC
28374-9191
US

IV. Provider business mailing address

293 OLMSTED BLVD STE 7
PINEHURST NC
28374-9191
US

V. Phone/Fax

Practice location:
  • Phone: 910-295-3344
  • Fax: 910-295-3165
Mailing address:
  • Phone: 910-295-3344
  • Fax: 910-295-3165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number9700591
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier890249K
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name: LISA P CORBETT
Title or Position: DELEGATED OFFICIAL
Credential:
Phone: 910-295-3344