NPI |
1710080296 |
The 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. The NPI number includes an ISO standard check-digit in the 10th position. There is no intelligence about the health care provider in the number. |
Entity Type Code |
2 |
The name prefix or salutation of the provider
if the provider is an individual; for example, Mr., Mrs., or Corporal. |
Employer Identification Number EIN |
|
The abbreviations for professional degrees or credentials used or held by the provider,
if the provider is an individual. Examples
are MD, DDS, CSW, CNA, AA, NP, RNA, or PSY. These credential designations
will not be verified by NPS. |
Provider Organization Name Legal Business Name |
LIBERTY MEDICAL SPECIALTIES INC |
Other last name by which the provider being identified is or has been known. |
Provider First Line Business Practice Location Address |
2224 S 17TH ST |
Other first name by which the provider being identified is or has been known (if an individual). This may be the same as the ‘‘Provider first name’’ if the provider is or has been known by a different last name only. |
Provider Business Practice Location Address City Name |
WILMINGTON |
Code identifying the type of other name. Codes are: 1 = former name; 2 = professional
name; 3 = doing business as (d/b/ a) name; 4 = former legal business name; 5 = other. |
Provider Business Practice Location Address State Name |
NC |
The first line location address of the provider
being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box. |
Provider Business Practice Location Address Postal Code |
284017515 |
The city name in the location address of the provider being identified. |
Provider Business Practice Location Address Country Code If outside U S |
US |
The country code in the location address of the provider being identified. |
Provider Business Practice Location Address Telephone Number |
9107638229 |
The telephone number associated with the location address of the provider being identified. |
Provider Enumeration Date |
9/7/2006 |
The country code in the location address of the provider being identified. |
Last Update Date |
10/3/2011 |
The telephone number associated with the location address of the provider being identified. |
Authorized Official Last Name |
JONES |
The fax number associated with the location
address of the provider being identified. |
Authorized Official First Name |
TAMARA |
The date the provider was assigned a unique identifier (assigned an NPI). |
Authorized Official Middle Name |
LYNN |
The date that a record was last updated or changed. |
Authorized Official Title or Position |
BILLING MANAGER |
The title or position of the authorized official. |
Authorized Official Telephone Number |
9106422250 |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
Healthcare Provider Taxonomy Code 1 |
3336H0001X |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
Healthcare Provider Primary Taxonomy Switch 1 |
Y |
|
Other Provider Identifier 1 |
3436676 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
Other Provider Identifier Type Code 1 |
01 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
Other Provider Identifier State 1 |
NC |
|
Other Provider Identifier Issuer 1 |
NCPDP# |
|
Other Provider Identifier 2 |
0473G |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
Other Provider Identifier Type Code 2 |
01 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
Other Provider Identifier State 2 |
NC |
|
Other Provider Identifier Issuer 2 |
BCBS IV |
|
Other Provider Identifier 3 |
0656091 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
Other Provider Identifier Type Code 3 |
05 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
Other Provider Identifier State 3 |
NC |
|
Other Provider Identifier 4 |
6800282 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
Other Provider Identifier Type Code 4 |
05 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
Other Provider Identifier State 4 |
NC |
|
Is Organization Subpart |
N |
|
Authorized Official Name Prefix Text |
MRS. |
|