MEDICARE: HOLDEN BEACH MEDICAL CENTER, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center	103587	NC

General Provider Information

NPI Number	:	1053547976
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOLDEN BEACH MEDICAL CENTER, PA

Provider Business Mailing Address
First Line	:	2930 HOLDEN BEACH RD SW
Second Line	:
City	:	SUPPLY
State	:	NC
Zip	:	28462-5702
Country	:	US
Telephone Number	:	910-842-5991
Fax Number	:	910-842-5994

Provider Business Practice Location Address
First Line	:	2930 HOLDEN BEACH RD SW
Second Line	:
City	:	SUPPLY
State	:	NC
Zip	:	28462-5702
Country	:	US
Telephone Number	:	910-842-5991
Fax Number	:	910-842-5994

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. HEATHER MERROW
Credential	:	PA-C
Telephone Number	:	910-842-5991

Provider Enumeration Date	:	06/05/2009
Last Update Date	:	06/05/2009

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