Provider Demographics
NPI:1447323191
Name:TARBORO INTERNAL MEDICINE PA
Entity type:Organization
Organization Name:TARBORO INTERNAL MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:EMMA
Authorized Official - Middle Name:
Authorized Official - Last Name:CASTILLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:252-823-0808
Mailing Address - Street 1:2704 N MAIN STREET
Mailing Address - Street 2:SUITE A
Mailing Address - City:TARBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27886-1918
Mailing Address - Country:US
Mailing Address - Phone:252-823-0808
Mailing Address - Fax:252-823-6010
Practice Address - Street 1:2704 N MAIN STREET
Practice Address - Street 2:SUITE A
Practice Address - City:TARBORO
Practice Address - State:NC
Practice Address - Zip Code:27886-1918
Practice Address - Country:US
Practice Address - Phone:252-823-0808
Practice Address - Fax:252-823-6010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200100655207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5900019Medicaid