=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114958576
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLADEN URGENT CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2006
-----------------------------------------------------
Last Update Date | 08/21/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300A E MCKAY ST
-----------------------------------------------------
City | ELIZABETHTOWN
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28337-9037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-862-1272
-----------------------------------------------------
Fax | 910-862-5501
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 40908
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28309-0908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-615-6949
-----------------------------------------------------
Fax | 910-615-9761
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP CORPORATE REVENUE CYCLE/MANAGED
-----------------------------------------------------
Name | MR. JOSEPH FISER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 910-615-5572
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QC0050X
-----------------------------------------------------
Taxonomy Name | Critical Access Hospital Clinic/Center
-----------------------------------------------------
License Number | H0154
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------