Basic Information
| Provider Information | |||||||||
| NPI: | 1255425443 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JOHNSTON ORTHOPAEDIC CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1538 | ||||||||
| Address2: | 540 NORTH ST | ||||||||
| City: | SMITHFIELD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275771538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199341094 | ||||||||
| FaxNumber: | 9199349044 | ||||||||
| Practice Location | |||||||||
| Address1: | 540 NORTH ST | ||||||||
| Address2: | |||||||||
| City: | SMITHFIELD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199341094 | ||||||||
| FaxNumber: | 9199349044 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 05/16/2008 | ||||||||
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| AuthorizedOfficialLastName: | BYLCIW | ||||||||
| AuthorizedOfficialFirstName: | STANLEY | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9199341094 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 26207 | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 890181A | 05 | NC | MEDICAID |