=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295881068
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SANDHILLS HEART SURGERY PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3419 MELROSE ROAD A
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28304-1608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-323-9922
-----------------------------------------------------
Fax | 910-323-9501
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3419 MELROSE ROAD A
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28304-1608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-323-9922
-----------------------------------------------------
Fax | 910-323-9501
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | HEART SURGEON
-----------------------------------------------------
Name | DR. ROBERT FIETSAM
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 910-323-9922
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 111444
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------