Organization
SOUTHPORT INTERNAL MEDICINE PA
Active
Organization
SOUTHPORT INTERNAL MEDICINE PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DOUGLAS K HILTZ JR. MD (PRESIDENT)
(910) 457-9127
Entity
Organization
Contact information
Practice address
1513 N HOWE ST, UNIT 6, SOUTHPORT, NC 28461-2769
(910) 457-9127
(910) 269-2884
Mailing address
PO BOX 10922, SOUTHPORT, NC 28461-0922
(910) 457-9127
(910) 269-2884
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
33376
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
34D0246020
CLIA WAIVED CERTIFICATE
NC
01
—
C201101100100-1
DEPT OF THE SECRETARY OF STATE CERTIFICATION NUMBER
NC
Enumeration date
02/25/2011
Last updated
07/06/2011
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