1548796584 NPI number — STATESVILLE HMA MEDICAL GROUP, LLC

Table of content: (NPI 1548796584)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548796584 NPI number — STATESVILLE HMA MEDICAL GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STATESVILLE HMA MEDICAL GROUP, LLC
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:
1548796584
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4000 MERIDIAN BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRANKLIN
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37067-6325
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-465-7230
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
35 RURITAN PARK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STONY POINT
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28678-8928
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-585-9373
Provider Business Practice Location Address Fax Number:
704-585-9397
Provider Enumeration Date:
05/11/2017

Additional Information

Authorized Official

Authorized Official Last Name:
JACKSON
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
L
Authorized Official Title or Position:
SR DIR PROV ENROLLMENT & ONBAORDING
Authorized Official Telephone Number:
615-465-3334

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  101815 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com