Basic Information
| Provider Information | |||||||||
| NPI: | 1740322593 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HALIFAX REGIONAL MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | HALIFAX MEMORIAL HOSPITAL | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 SMITH CHURCH RD | ||||||||
| Address2: | |||||||||
| City: | ROANOKE RAPIDS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278704914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2525358011 | ||||||||
| FaxNumber: | 2525358466 | ||||||||
| Practice Location | |||||||||
| Address1: | 250 SMITH CHURCH RD | ||||||||
| Address2: | |||||||||
| City: | ROANOKE RAPIDS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278704914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2525358011 | ||||||||
| FaxNumber: | 2525358466 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2007 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | JENSEN | ||||||||
| AuthorizedOfficialFirstName: | SHERRY | ||||||||
| AuthorizedOfficialMiddleName: | EMERY | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2525358005 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | H0230 | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 8000165 | 05 | NC | MEDICAID |