Basic Information
Provider Information | |||||||||
NPI: | 1417941352 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SCOTLAND MEMORIAL HOSPITAL, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MAXTON FAMILY PRACTICE CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 604093 | ||||||||
Address2: |   | ||||||||
City: | CHARLOTTE | ||||||||
State: | NC | ||||||||
PostalCode: | 282604093 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9102917000 | ||||||||
FaxNumber: | 9108445840 | ||||||||
Practice Location | |||||||||
Address1: | 1001 W. MARTIN LUTHER KING JR. DR. | ||||||||
Address2: |   | ||||||||
City: | MAXTON | ||||||||
State: | NC | ||||||||
PostalCode: | 28364 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9108444077 | ||||||||
FaxNumber: | 9108445840 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/07/2005 | ||||||||
LastUpdateDate: | 09/22/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | STONGE | ||||||||
AuthorizedOfficialFirstName: | LUCIEN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 9102917547 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/22/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X |   | NC | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
ID | Type | State | Issuer | Description | 34-3987 | 05 | NC |   | MEDICAID | 0262L | 01 | NC | BCBS | OTHER | NPA922 | 05 | SC |   | MEDICAID |