Provider Demographics
NPI:1194953307
Name:IREDELL PHYSICIAN NETWORK LLC
Entity type:Organization
Organization Name:IREDELL PHYSICIAN NETWORK LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:PURCELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-878-4569
Mailing Address - Street 1:365 BROOKDALE DR
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28677-4103
Mailing Address - Country:US
Mailing Address - Phone:704-872-3630
Mailing Address - Fax:704-872-0049
Practice Address - Street 1:365 BROOKDALE DR
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-4103
Practice Address - Country:US
Practice Address - Phone:704-872-3630
Practice Address - Fax:704-872-0049
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IREDELL PHYSICIAN NETWORK LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-06-25
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5913292Medicaid