=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396731485
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEVEN MICHAEL JURISICH MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2005
-----------------------------------------------------
Last Update Date | 04/14/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1139 CARTHAGE ST SUITE 110
-----------------------------------------------------
City | SANFORD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27330-4111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-775-7232
-----------------------------------------------------
Fax | 919-775-1731
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1139 CARTHAGE ST SUITE 110
-----------------------------------------------------
City | SANFORD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27330-4111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-775-7232
-----------------------------------------------------
Fax | 919-775-1731
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 9300171
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------