Basic Information
| Provider Information | |||||||||
| NPI: | 1437452513 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST LUKES PHYSICIAN NETWORK, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FOOTHILLS MEDICAL ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 602527 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282602527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8288945627 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 801 W MILLS ST | ||||||||
| Address2: | SUITE C | ||||||||
| City: | COLUMBUS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287228494 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8288945627 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2010 | ||||||||
| LastUpdateDate: | 01/11/2017 | ||||||||
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| AuthorizedOfficialLastName: | PRESNELL | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
| AuthorizedOfficialMiddleName: | WEATHERS | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8288940954 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST LUKES PHYSICIAN NETWORK INC | ||||||||
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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 | 1437452513 | 05 | NC | MEDICAID | 5917245 | 05 | NC | MEDICAID |