Basic Information
| Provider Information | |||||||||
| NPI: | 1821325010 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STANLY MEDICAL SERVICES | ||||||||
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| OtherOrganizationName: | STANLY SURGICAL WEIGHT LOSS CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 320 YADKIN ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | ALBEMARLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280013447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049837320 | ||||||||
| FaxNumber: | 7049836153 | ||||||||
| Practice Location | |||||||||
| Address1: | 320 YADKIN ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | ALBEMARLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280013447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049837320 | ||||||||
| FaxNumber: | 7049836153 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2009 | ||||||||
| LastUpdateDate: | 07/17/2013 | ||||||||
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| AuthorizedOfficialLastName: | HARRIS | ||||||||
| AuthorizedOfficialFirstName: | MARINDY | ||||||||
| AuthorizedOfficialMiddleName: | BOST | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER REVENUE CYCLE | ||||||||
| AuthorizedOfficialTelephone: | 7049837320 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QB0002X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Bariatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 023KY | 01 | NC | BCBS | OTHER | 5913327 | 05 | NC | MEDICAID |