=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467656710
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LENOIR MEMORIAL HOSPITAL INCORPORATED
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2007
-----------------------------------------------------
Last Update Date | 01/26/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 518 PLAZA BLVD SUITE 2
-----------------------------------------------------
City | KINSTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28501-1604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-522-7000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 AIRPORT RD
-----------------------------------------------------
City | KINSTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28501-1604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-522-7000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. GARY ELBRIDGE BLACK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 252-522-7798
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | H0043
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------