NPIMap

Organization Active NPI

Lifesource of North Carolina

  • Internal Medicine Physician
  • Wilmington, NC
National Provider Identifier
1811286156
Registry record updated Dec 29, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
Legal business name
LIFESOURCE OF NORTH CAROLINA
Practice address
3205 Randall Pkwy
Suite 105
Wilmington, NC 28403
Phone
(910) 742-9243
Fax
(888) 746-1787
NPI assigned
Apr 6, 2011
Last updated
Dec 29, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 29, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Peggy L Baddour
Title
President/Owner
Phone
(910) 777-9165

Specialties & licenses 7

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical PsychologistGroup: 193200000X MULTI-SPECIALTY GROUP 103TC0700X
Clinical Social WorkerGroup: 193200000X MULTI-SPECIALTY GROUP 1041C0700X
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Internal Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207R00000X Primary
Psychiatry PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2084P0800X
Physician AssistantGroup: 193200000X MULTI-SPECIALTY GROUP 363A00000X
Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363L00000X

Addresses

Primary practice location

3205 Randall Pkwy
Suite 105
Wilmington, NC 28403

Mailing address

PO Box 538622
Lifesource of North Carolina
Atlanta, GA 30353-8622
Phone (910) 742-9243

Other practice location 1

4002 Executive Park Blvd Ste 300
Southport, NC 28461-9080
Phone (910) 742-9243

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NC

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20110505000743 NC Part B Supplier - Clinic/Group Practice 7416132428 Receives reassigned benefits from 97 practitioners
Practice locations: Clayton, NC; Wilmington, NC

Other NPIs with the same Medicare PAC ID 8

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory

Locations

390 Park Ave
Hazard, KY 41701
Phone (606) 439-2306

3205 Randall Pkwy
Wilmington, NC 28403
Phone (919) 521-0833

3205 Randall Pkwy
Ste 205
Wilmington, NC 28403
Phone (910) 338-0001

2 Griffith Rd
Greenville, SC 29607
Phone (864) 276-8583

Practitioners & affiliated clinicians

Practitioners 217

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 217

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1302048000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1640736000000",
    "number": "1811286156",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 538622",
            "address_2": "LIFESOURCE OF NORTH CAROLINA",
            "city": "ATLANTA",
            "state": "GA",
            "postal_code": "303538622",
            "telephone_number": "910-742-9243",
            "fax_number": "888-746-1787"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3205 RANDALL PKWY",
            "address_2": "SUITE 105",
            "city": "WILMINGTON",
            "state": "NC",
            "postal_code": "28403",
            "telephone_number": "910-742-9243",
            "fax_number": "888-746-1787"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "4002 Executive Park Blvd Ste 300",
            "address_purpose": "LOCATION",
            "city": "Southport",
            "state": "NC",
            "postal_code": "284619080",
            "country_code": "US",
            "telephone_number": "910-742-9243",
            "fax_number": "888-746-1787",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "LIFESOURCE OF NORTH CAROLINA",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-04-06",
        "last_updated": "2021-12-29",
        "certification_date": "2021-12-29",
        "status": "A",
        "authorized_official_last_name": "BADDOUR",
        "authorized_official_first_name": "PEGGY",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "PRESIDENT/OWNER",
        "authorized_official_telephone_number": "910-777-9165"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist, Clinical",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Social Worker, Clinical",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physician Assistant",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Wilmington, NC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 29, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.