Basic Information
| Provider Information | |||||||||
| NPI: | 1598765935 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HILDEBRAN MEDICAL CLINIC, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 829 | ||||||||
| Address2: | |||||||||
| City: | HILDEBRAN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286370829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8283973522 | ||||||||
| FaxNumber: | 8283975271 | ||||||||
| Practice Location | |||||||||
| Address1: | 107 S CENTER ST | ||||||||
| Address2: | |||||||||
| City: | HILDEBRAN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286378304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8283973522 | ||||||||
| FaxNumber: | 8283975271 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2005 | ||||||||
| LastUpdateDate: | 04/07/2020 | ||||||||
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| AuthorizedOfficialLastName: | DAVIDSON | ||||||||
| AuthorizedOfficialFirstName: | ILAR | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8283973522 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 04/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 33531 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 790274T | 05 | NC | MEDICAID |