Basic Information
| Provider Information | |||||||||
| NPI: | 1962894246 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MISSION MEDICAL ASSOCIATES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MMA PSYCHIATRIC SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 602373 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282602373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282502833 | ||||||||
| FaxNumber: | 8282502932 | ||||||||
| Practice Location | |||||||||
| Address1: | 190 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | HIGHLANDS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287417600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282134502 | ||||||||
| FaxNumber: | 8282134540 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2015 | ||||||||
| LastUpdateDate: | 02/24/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOGGARD-GREEN | ||||||||
| AuthorizedOfficialFirstName: | JILL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 8282131111 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | SENIOR VP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.