MEDICARE: BOILING SPRING LAKES FAMILY MEDICINE, PC

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	207Q00000X	Family Medicine Physician		NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1730275090
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOILING SPRING LAKES FAMILY MEDICINE, PC

Provider Business Mailing Address
First Line	:	3599 GEORGE II HWY
Second Line	:
City	:	SOUTHPORT
State	:	NC
Zip	:	28461-7793
Country	:	US
Telephone Number	:	910-845-3244
Fax Number	:	910-845-3276

Provider Business Practice Location Address
First Line	:	3599 GEORGE II HWY
Second Line	:
City	:	SOUTHPORT
State	:	NC
Zip	:	28461-7793
Country	:	US
Telephone Number	:	910-845-3244
Fax Number	:	910-845-3276

Authorized Official
Title or Position	:	OWNER
Name	:	DOMENIC A PALAGRUTO II
Credential	:	D.O.
Telephone Number	:	910-845-3244

Provider Enumeration Date	:	10/05/2006
Last Update Date	:	08/22/2020

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Directions to “BOILING SPRING LAKES FAMILY MEDICINE, PC ” Practice Location

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