Basic Information
Provider Information | |||||||||
NPI: | 1619606316 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HENDERSON COUNTY HOSPITAL CORPORATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PARDEE BLUEMD-2775 HENDERSONVILLE ROAD | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5221 PARAMOUNT PKWY STE 440 | ||||||||
Address2: |   | ||||||||
City: | MORRISVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 275605491 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9849741190 | ||||||||
FaxNumber: | 9849741311 | ||||||||
Practice Location | |||||||||
Address1: | 2775 HENDERSONVILLE RD | ||||||||
Address2: |   | ||||||||
City: | ARDEN | ||||||||
State: | NC | ||||||||
PostalCode: | 287040060 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8286948900 | ||||||||
FaxNumber: | 8286948901 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/08/2022 | ||||||||
LastUpdateDate: | 10/26/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SUNDAY | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: | LYNN | ||||||||
AuthorizedOfficialTitleorPosition: | VP, CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 8286961175 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: | JR. | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/26/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 261QF0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.