Provider Demographics
NPI:1730275090
Name:BOILING SPRING LAKES FAMILY MEDICINE, PC
Entity type:Organization
Organization Name:BOILING SPRING LAKES FAMILY MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOMENIC
Authorized Official - Middle Name:A
Authorized Official - Last Name:PALAGRUTO
Authorized Official - Suffix:II
Authorized Official - Credentials:DO
Authorized Official - Phone:910-845-3244
Mailing Address - Street 1:3599 GEORGE II HWY
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:NC
Mailing Address - Zip Code:28461-7793
Mailing Address - Country:US
Mailing Address - Phone:910-845-3244
Mailing Address - Fax:910-845-3276
Practice Address - Street 1:3599 GEORGE II HWY
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:NC
Practice Address - Zip Code:28461-7793
Practice Address - Country:US
Practice Address - Phone:910-845-3244
Practice Address - Fax:910-845-3276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8913720Medicaid
NC8913720Medicaid
NC2340764Medicare ID - Type Unspecified