Basic Information
| Provider Information | |||||||||
| NPI: | 1790099927 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PARDEE HENDERSONVILLE FAMILY HEALTH CENTER-ETOWAH | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 63314 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282633314 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 6503 BREVARD RD | ||||||||
| Address2: | |||||||||
| City: | ETOWAH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287298739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8288904156 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2010 | ||||||||
| LastUpdateDate: | 11/02/2010 | ||||||||
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| AuthorizedOfficialLastName: | HOUSE | ||||||||
| AuthorizedOfficialFirstName: | ALAN | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8286961000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HENDERSON COUNTY HOSPITAL CORPORATION D/B/A PARDEE MEDICAL ASSOCIATES | ||||||||
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| AuthorizedOfficialCredential: | CFO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0185X | 01 | NC | BLUE CROSS BLUE SHIELD | OTHER |