Basic Information
| Provider Information | |||||||||
| NPI: | 1588898480 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STANLY MEDICAL SERVICES | ||||||||
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| OtherOrganizationName: | ALBEMARLE INTERNAL MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 320 YADKIN ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | ALBEMARLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280013447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049837320 | ||||||||
| FaxNumber: | 7049836153 | ||||||||
| Practice Location | |||||||||
| Address1: | 929 N 2ND ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | ALBEMARLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280013363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049831805 | ||||||||
| FaxNumber: | 7049825985 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2009 | ||||||||
| LastUpdateDate: | 05/23/2012 | ||||||||
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| AuthorizedOfficialLastName: | MARINO | ||||||||
| AuthorizedOfficialFirstName: | BRAD | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | VP | ||||||||
| AuthorizedOfficialTelephone: | 7049838220 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 021V8 | 01 | NC | BCBS | OTHER | 5911755 | 05 | NC | MEDICAID |