Provider Demographics
NPI:1063556728
Name:DOUGLAS DUSSEL PRITCHARD MD PLLC
Entity type:Organization
Organization Name:DOUGLAS DUSSEL PRITCHARD MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:DUSSEL
Authorized Official - Last Name:PRITCHARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-818-0840
Mailing Address - Street 1:610 SIGNAL HILL DRIVE EXT
Mailing Address - Street 2:SUITE 100
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28625-4337
Mailing Address - Country:US
Mailing Address - Phone:704-818-0480
Mailing Address - Fax:704-818-0490
Practice Address - Street 1:610 SIGNAL HILL DRIVE EXT
Practice Address - Street 2:SUITE 100
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625-4337
Practice Address - Country:US
Practice Address - Phone:704-818-0480
Practice Address - Fax:704-818-0490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC18045207LP2900X
NC10845261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC132YCOtherBCBS
NC7870927OtherAETNA
NC196255OtherMEDCOST
NC209727AOtherMEDICARE INDIVIDUAL PTAN
NCDG1403OtherRR MEDICARE
NCC87629Medicare UPIN
NC7870927OtherAETNA