1174812507 NPI number — STANLY MEDICAL SERVICES

Table of content: (NPI 1174812507)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174812507 NPI number — STANLY MEDICAL SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STANLY MEDICAL SERVICES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174812507
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/17/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
320 YADKIN ST
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
ALBEMARLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28001-3447
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-983-7320
Provider Business Mailing Address Fax Number:
704-983-6153

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
923 N 2ND ST
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
ALBEMARLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28001-3317
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-986-6662
Provider Business Practice Location Address Fax Number:
704-986-6663
Provider Enumeration Date:
04/06/2011

Additional Information

Authorized Official

Authorized Official Last Name:
HARRIS
Authorized Official First Name:
MARINDY
Authorized Official Middle Name:
BOST
Authorized Official Title or Position:
MANAGER REVENUE CYCLE
Authorized Official Telephone Number:
704-983-7320

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 024P4 . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 5917199 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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