Basic Information
| Provider Information | |||||||||
| NPI: | 1265499206 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STALLION | ||||||||
| FirstName: | ANTHONY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 601888 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282601888 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7044032662 | ||||||||
| FaxNumber: | 7044032670 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 MEDICAL PARK DR | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280252966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7044032662 | ||||||||
| FaxNumber: | 7044032670 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 12/06/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0120X | 35060022S | OH | N | Allopathic & Osteopathic Physicians | Surgery | Pediatric Surgery | 2086S0120X | 2013-01542 | NC | Y | Allopathic & Osteopathic Physicians | Surgery | Pediatric Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0803198 | 05 | OH | MEDICAID | 1265499206 | 05 | NC | MEDICAID | Q0154E | 05 | SC | MEDICAID |