Basic Information
Provider Information | |||||||||
NPI: | 1023099454 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | STANLY MEDICAL SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ALBEMARLE ORTHOPEDICS & SPORTS MEDICINE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 320 YADKIN ST | ||||||||
Address2: | STE B | ||||||||
City: | ALBEMARLE | ||||||||
State: | NC | ||||||||
PostalCode: | 28001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7049837320 | ||||||||
FaxNumber: | 7049836153 | ||||||||
Practice Location | |||||||||
Address1: | 105 YADKIN ST | ||||||||
Address2: | STE 101 | ||||||||
City: | ALBEMARLE | ||||||||
State: | NC | ||||||||
PostalCode: | 28001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7049835195 | ||||||||
FaxNumber: | 7049822665 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/11/2005 | ||||||||
LastUpdateDate: | 07/17/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HARRIS | ||||||||
AuthorizedOfficialFirstName: | MARINDY | ||||||||
AuthorizedOfficialMiddleName: | BOST | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGER REVENUE CYCLE | ||||||||
AuthorizedOfficialTelephone: | 7049837320 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
ID | Type | State | Issuer | Description | 790200F | 05 | NC |   | MEDICAID |