MEDICARE: CAPE FEAR ORTHOPAEDIC CLINIC, PA

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	207XP3100X	Pediatric Orthopaedic Surgery Physician
2	207XS0106X	Orthopaedic Hand Surgery Physician
3	207XX0004X	Orthopaedic Foot and Ankle Surgery Physician
4	207XX0005X	Sports Medicine (Orthopaedic Surgery) Physician
5	224Z00000X	Occupational Therapy Assistant
6	225100000X	Physical Therapist
7	225200000X	Physical Therapy Assistant
8	225X00000X	Occupational Therapist
9	363AS0400X	Surgical Physician Assistant
10	207X00000X	Orthopaedic Surgery Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01185	OTHER	NC	BCBS GROUP ID NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1245204494
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAPE FEAR ORTHOPAEDIC CLINIC, PA

Provider Business Mailing Address
First Line	:	4140 FERNCREEK DR
Second Line	:	SUITE 801
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28314-2572
Country	:	US
Telephone Number	:	910-484-2171
Fax Number	:	910-484-4568

Provider Business Practice Location Address
First Line	:	4140 FERNCREEK DR
Second Line	:	SUITE 801
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28314-2572
Country	:	US
Telephone Number	:	910-484-2171
Fax Number	:	910-484-4568

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. BRADLEY J BROUSSARD
Credential	:	MD
Telephone Number	:	910-484-2171

Provider Enumeration Date	:	02/15/2006
Last Update Date	:	08/06/2019

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