Basic Information
Provider Information | |||||||||
NPI: | 1972814382 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | STANLY MEDICAL SERVICES, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | STANLY UROLOGY SERVICES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 320 YADKIN ST STE B | ||||||||
Address2: |   | ||||||||
City: | ALBEMARLE | ||||||||
State: | NC | ||||||||
PostalCode: | 280013447 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7049837320 | ||||||||
FaxNumber: | 7049836153 | ||||||||
Practice Location | |||||||||
Address1: | 1009 N 6TH ST | ||||||||
Address2: |   | ||||||||
City: | ALBEMARLE | ||||||||
State: | NC | ||||||||
PostalCode: | 280013551 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7049822800 | ||||||||
FaxNumber: | 7049822830 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/30/2010 | ||||||||
LastUpdateDate: | 07/17/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HARRIS | ||||||||
AuthorizedOfficialFirstName: | MARINDY | ||||||||
AuthorizedOfficialMiddleName: | BOST | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGER REVENUE CYCLE | ||||||||
AuthorizedOfficialTelephone: | 7049837320 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |   |
ID Information
ID | Type | State | Issuer | Description | 023KX | 01 | NC | BCBS | OTHER | 5915190 | 05 | NC |   | MEDICAID |