Basic Information
| Provider Information | |||||||||
| NPI: | 1912218348 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SCOTLAND REGIONAL HEALTH NETWORK | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | HARRIS FAMILY PRACTICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 602458 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282602458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102766767 | ||||||||
| FaxNumber: | 9102767877 | ||||||||
| Practice Location | |||||||||
| Address1: | 700A PROGRESS PL | ||||||||
| Address2: | |||||||||
| City: | LAURINBURG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283525545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102766767 | ||||||||
| FaxNumber: | 9102767877 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2010 | ||||||||
| LastUpdateDate: | 01/11/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PRACHT | ||||||||
| AuthorizedOfficialFirstName: | MATHEW | ||||||||
| AuthorizedOfficialMiddleName: | DAVID | ||||||||
| AuthorizedOfficialTitleorPosition: | TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 9102917920 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SCOTLAND REGIONAL HEALTH NETWORK | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | NPB390 | 05 | SC | MEDICAID | 1912218348 | 05 | NC | MEDICAID | 5915169 | 05 | NC | MEDICAID |