Provider Demographics
NPI:1316082076
Name:STATESVILLE PRIMARY CARE PLLC
Entity type:Organization
Organization Name:STATESVILLE PRIMARY CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ELLIOTT
Authorized Official - Middle Name:J
Authorized Official - Last Name:VIZEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-924-9423
Mailing Address - Street 1:3308 PRESTON RD
Mailing Address - Street 2:SUIITE 350-165
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-7453
Mailing Address - Country:US
Mailing Address - Phone:704-924-9423
Mailing Address - Fax:
Practice Address - Street 1:708 HARTNESS RD
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-3425
Practice Address - Country:US
Practice Address - Phone:704-924-9423
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2011-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9600416207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2327297Medicare ID - Type UnspecifiedPROVIDER NUMBER