1205928223 NPI number — TEDRA GILMORE MD

Table of content: TEDRA GILMORE MD (NPI 1205928223)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205928223 NPI number — TEDRA GILMORE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GILMORE
Provider First Name:
TEDRA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205928223
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/26/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7141 SECURITY BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21244-1800
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-777-7904
Provider Business Mailing Address Fax Number:
386-258-6882

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 MCALPINE LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAURINBURG
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28352-4637
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-504-8530
Provider Business Practice Location Address Fax Number:
910-291-7180
Provider Enumeration Date:
09/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  ME 98980 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 2022-02131 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 278400900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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