Basic Information
| Provider Information | |||||||||
| NPI: | 1225563760 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HENDERSON COUNTY HOSPITAL CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PARDEE MEDICAL ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 27877 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841270877 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286948350 | ||||||||
| FaxNumber: | 8286947654 | ||||||||
| Practice Location | |||||||||
| Address1: | 2695 HENDERSONVILLE RD | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | ARDEN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287048576 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286948420 | ||||||||
| FaxNumber: | 8286948421 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2017 | ||||||||
| LastUpdateDate: | 04/21/2017 | ||||||||
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| AuthorizedOfficialLastName: | KIRBY | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8286948350 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HENDERSON COUNTY HOSPITAL CORPORATION | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0185X | 01 | NC | BCBS NC | OTHER | CF8423 | 01 | NC | RR MEDICARE | OTHER |