Basic Information
| Provider Information | |||||||||
| NPI: | 1306183512 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JEPSEN | ||||||||
| FirstName: | ERIN | ||||||||
| MiddleName: | STEPHANY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FITZPATRICK | ||||||||
| OtherFirstName: | ERIN | ||||||||
| OtherMiddleName: | STEPHANY | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 60516 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282600516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362778850 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3333 SILAS CREEK PKWY | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271033013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362778800 | ||||||||
| FaxNumber: | 3362778850 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2013 | ||||||||
| LastUpdateDate: | 04/25/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 201500507 | NC | N | Allopathic & Osteopathic Physicians | Internal Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RH0003X | 201500507 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
No ID Information.