Provider Demographics
NPI:1902887292
Name:KINSTON DIAGNOSTIC GROUP PA
Entity Type:Organization
Organization Name:KINSTON DIAGNOSTIC GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:HARPER
Authorized Official - Last Name:WEST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:252-522-3661
Mailing Address - Street 1:109 AIRPORT ROAD
Mailing Address - Street 2:
Mailing Address - City:KINSTON
Mailing Address - State:NC
Mailing Address - Zip Code:28501-1693
Mailing Address - Country:US
Mailing Address - Phone:252-522-3661
Mailing Address - Fax:252-522-0117
Practice Address - Street 1:109 AIRPORT ROAD
Practice Address - Street 2:
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28501-1693
Practice Address - Country:US
Practice Address - Phone:252-522-3661
Practice Address - Fax:252-522-0117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-14
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
02965OtherBCBS
NC7902965Medicaid
0971Medicare ID - Type Unspecified