Basic Information
| Provider Information | |||||||||
| NPI: | 1548796584 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STATESVILLE HMA MEDICAL GROUP, LLC | ||||||||
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| OtherOrganizationName: | DAVIS MEDICAL GROUP FAMILY PRACTICE STONY POINT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4000 MERIDIAN BLVD | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370676325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154657230 | ||||||||
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| Practice Location | |||||||||
| Address1: | 35 RURITAN PARK RD | ||||||||
| Address2: | |||||||||
| City: | STONY POINT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286788928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045859373 | ||||||||
| FaxNumber: | 7045859397 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2017 | ||||||||
| LastUpdateDate: | 01/14/2022 | ||||||||
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| AuthorizedOfficialLastName: | JACKSON | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | SR DIR PROV ENROLLMENT & ONBAORDING | ||||||||
| AuthorizedOfficialTelephone: | 6154653334 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 101815 | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.