Basic Information
| Provider Information | |||||||||
| NPI: | 1992701486 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRYNN MARR HOSPITAL INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 192 VILLAGE DR | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285467238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9105771400 | ||||||||
| FaxNumber: | 9105772766 | ||||||||
| Practice Location | |||||||||
| Address1: | 192 VILLAGE DR | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285467238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9105771400 | ||||||||
| FaxNumber: | 9105772766 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2005 | ||||||||
| LastUpdateDate: | 07/23/2013 | ||||||||
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| AuthorizedOfficialLastName: | SHACKELFORD | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9105772770 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283Q00000X | MHH0190 | NC | Y | Hospitals | Psychiatric Hospital |
ID Information
| ID | Type | State | Issuer | Description | 00066 | 01 | NC | BCBS | OTHER | 3404016 | 05 | NC | MEDICAID |