1912946336 NPI number — DR. SAMUEL JAY PERETSMAN M.D.

Table of content: DR. SAMUEL JAY PERETSMAN M.D. (NPI 1912946336)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912946336 NPI number — DR. SAMUEL JAY PERETSMAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PERETSMAN
Provider First Name:
SAMUEL
Provider Middle Name:
JAY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1912946336
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/30/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 36488
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28236-6488
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-248-3400
Provider Business Mailing Address Fax Number:
704-337-8387

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 QUEENS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28204-3217
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-372-5180
Provider Business Practice Location Address Fax Number:
704-376-6280
Provider Enumeration Date:
06/05/2006

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: 208800000X , with the licence number:  89031 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208800000X , with the licence number: 9500688 , 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: 10465 . This is a "PARTNERS PROVIDER #" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 66833 . This is a "BCBS INDI PROVIDER #" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 340016821 . This is a "RAILROAD MEDICARE INDI #" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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