Basic Information
| Provider Information | |||||||||
| NPI: | 1356421853 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PINEHURST MEDICAL CLINIC INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PINEHURST MEDICAL CLINIC ENDOSCOPY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 205 PAGE RD | ||||||||
| Address2: | |||||||||
| City: | PINEHURST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283748798 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102955511 | ||||||||
| FaxNumber: | 9102353443 | ||||||||
| Practice Location | |||||||||
| Address1: | 15 REGIONAL DR | ||||||||
| Address2: | |||||||||
| City: | PINEHURST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283748850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102955511 | ||||||||
| FaxNumber: | 9102353432 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 03/14/2022 | ||||||||
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| AuthorizedOfficialLastName: | ENFINGER | ||||||||
| AuthorizedOfficialFirstName: | BRANDON | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9102353004 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | AS0073 | NC | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 3409941 | 05 | NC | MEDICAID |