Healthcare Provider Details

I. General information

NPI: 1255668356
Provider Name (Legal Business Name): ECU PHYSICIANS WASHINGTON OFFICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2009
Last Update Date: 11/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1240 COWELL FARM RD
WASHINGTON NC
27889-3440
US

IV. Provider business mailing address

PO BOX 751069
CHARLOTTE NC
28275-1069
US

V. Phone/Fax

Practice location:
  • Phone: 252-744-2096
  • Fax:
Mailing address:
  • Phone: 252-744-3194
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number30079
License Number StateNC

VIII. Authorized Official

Name: DR. NICHOLAS BENSON
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 252-744-7400