=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679571574
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BECKFORD AVENUE MEDICAL CENTER PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2005
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 176 BECKFORD DR
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27536-2589
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-492-2161
-----------------------------------------------------
Fax | 252-438-2888
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 176 BECKFORD DR
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27536-2589
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-492-2161
-----------------------------------------------------
Fax | 252-438-2888
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JAMES E KENNEY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 252-492-2161
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------