Basic Information
| Provider Information | |||||||||
| NPI: | 1962584177 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CROWN HEALTH CARE PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SPRINGS ROAD FAMILY PRACTICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2359 SPRINGS RD NE | ||||||||
| Address2: | |||||||||
| City: | HICKORY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286013067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282569853 | ||||||||
| FaxNumber: | 8282561255 | ||||||||
| Practice Location | |||||||||
| Address1: | 2359 SPRINGS RD NE | ||||||||
| Address2: | |||||||||
| City: | HICKORY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286013067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282569853 | ||||||||
| FaxNumber: | 8282561255 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 11/12/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STEWART | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATIVE ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 8284659730 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | NC | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | CN8132 | 01 | NC | MEDICARE RAILROAD | OTHER | 790148H | 05 | NC | MEDICAID |