Basic Information
Provider Information | |||||||||
NPI: | 1144201286 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | STANLY MEDICAL SERVICES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | OAKBORO MEDICAL SERVICES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 320 YADKIN ST | ||||||||
Address2: | STE B | ||||||||
City: | ALBEMARLE | ||||||||
State: | NC | ||||||||
PostalCode: | 280013447 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7049837320 | ||||||||
FaxNumber: | 7049836153 | ||||||||
Practice Location | |||||||||
Address1: | 112 E 1ST ST | ||||||||
Address2: |   | ||||||||
City: | OAKBORO | ||||||||
State: | NC | ||||||||
PostalCode: | 281299715 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7044853319 | ||||||||
FaxNumber: | 7044853310 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/07/2005 | ||||||||
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 | 261QR1300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
ID | Type | State | Issuer | Description | 348904C | 01 | NC | MEDICAID C | OTHER | 348904A | 05 | NC |   | MEDICAID | 348904 | 01 | NC | MEDICARE A | OTHER | 0235P | 01 | NC | BCBS | OTHER |