Basic Information
| Provider Information | |||||||||
| NPI: | 1841309903 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MENDELSOHN | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | KAISER | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KAISER | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | N. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 602120 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282602120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8033295131 | ||||||||
| FaxNumber: | 8033666600 | ||||||||
| Practice Location | |||||||||
| Address1: | 1656 RIVERCHASE BLVD | ||||||||
| Address2: | SUITE 2400 | ||||||||
| City: | ROCK HILL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297322084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8033295131 | ||||||||
| FaxNumber: | 8033663300 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 11/17/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 200500211 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5905738 | 05 | NC | MEDICAID | 1841309903 | 05 | NC | MEDICAID | 375374 | 05 | SC | MEDICAID |