Basic Information
| Provider Information | |||||||||
| NPI: | 1467826073 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MISSION HOSPITAL INC | ||||||||
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| OtherOrganizationName: | FULLERTON GENETICS CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 602373 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282602373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282131500 | ||||||||
| FaxNumber: | 8286816570 | ||||||||
| Practice Location | |||||||||
| Address1: | 11 VANDERBILT PARK DR | ||||||||
| Address2: | |||||||||
| City: | ASHEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 288031700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282130022 | ||||||||
| FaxNumber: | 8282130039 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2015 | ||||||||
| LastUpdateDate: | 07/26/2016 | ||||||||
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| AuthorizedOfficialLastName: | HATHAWAY | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF MEDICAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8282131111 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 170100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Medical Genetics, Ph.D. Medical Genetics |
No ID Information.