=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255397725
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAPE FEAR REGIONAL UROLOGICAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2006
-----------------------------------------------------
Last Update Date | 01/09/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1537 OWEN PARK LN
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28304-3454
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-485-8801
-----------------------------------------------------
Fax | 910-485-5605
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1537 OWEN PARK LN
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28304-3454
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-485-8801
-----------------------------------------------------
Fax | 910-485-5605
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | SUSAN WILSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 910-485-8801
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number | 9400496
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------