Basic Information
| Provider Information | |||||||||
| NPI: | 1609010453 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HEALTHSTAT, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4601 CHARLOTTE PARK DR | ||||||||
| Address2: | SUITE 390 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282171915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045296161 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4800 DEERWOOD CAMPUS PKWY | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322466498 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045296161 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2009 | ||||||||
| LastUpdateDate: | 04/23/2009 | ||||||||
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| AuthorizedOfficialLastName: | KNOOP | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7045296161 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.