Basic Information
| Provider Information | |||||||||
| NPI: | 1942277454 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOT SPRINGS HEALTH PROGRAM, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MASHBURN MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 69 | ||||||||
| Address2: | |||||||||
| City: | MARSHALL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287530069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286490800 | ||||||||
| FaxNumber: | 8286493786 | ||||||||
| Practice Location | |||||||||
| Address1: | 590 MEDICAL PARK DR | ||||||||
| Address2: | |||||||||
| City: | MARSHALL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287536807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286493500 | ||||||||
| FaxNumber: | 8286491032 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2006 | ||||||||
| LastUpdateDate: | 07/28/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STROM | ||||||||
| AuthorizedOfficialFirstName: | TERESA | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8286490800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HOT SPRINGS HEALTH PROGRAM, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 1942277454 | 05 | NC | MEDICAID | CA4200 | 01 | NC | RAIL ROAD MEDICARE | OTHER | 01799 | 01 | NC | BCBS | OTHER |