Provider Demographics
NPI:1902963937
Name:WHITEVILLE MEDICAL ASSOCIATES PA
Entity Type:Organization
Organization Name:WHITEVILLE MEDICAL ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:W
Authorized Official - Last Name:TRAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-642-6121
Mailing Address - Street 1:823 JEFFERSON ST
Mailing Address - Street 2:PO BOX 1528
Mailing Address - City:WHITEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28472
Mailing Address - Country:US
Mailing Address - Phone:910-642-6121
Mailing Address - Fax:910-642-8457
Practice Address - Street 1:823 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:WHITEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28472
Practice Address - Country:US
Practice Address - Phone:910-642-6121
Practice Address - Fax:910-642-8457
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20979207Q00000X
NC24304207R00000X
NC39134208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7902940Medicaid
NCCD8805OtherRAILROAD MEDICARE CLINIC
SCNPA538OtherSOUTH CAROLINA MEDICAID
SCNPA538OtherSOUTH CAROLINA MEDICAID