Healthcare Provider Details

I. General information

NPI: 1306855770
Provider Name (Legal Business Name): HALIFAX GASTROENTEROLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 02/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1007 GREGORY DR
ROANOKE RAPIDS NC
27870-6451
US

IV. Provider business mailing address

1007 GREGORY DR
ROANOKE RAPIDS NC
27870-6451
US

V. Phone/Fax

Practice location:
  • Phone: 252-535-6478
  • Fax: 252-535-6483
Mailing address:
  • Phone: 252-535-6478
  • Fax: 252-535-6483

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number9700163
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberAS0141
License Number StateNC

VIII. Authorized Official

Name: MRS. PADMA DEVI YERRA
Title or Position: OFF MANAGER
Credential:
Phone: 252-535-6478