Basic Information
| Provider Information | |||||||||
| NPI: | 1992846570 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HALIFAX REGIONAL MEDICAL CENTER INC | ||||||||
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| OtherOrganizationName: | HALIFAX MEMORIAL HOSPITAL | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 SMITH CHURCH RD | ||||||||
| Address2: | P.O. BOX 1089 | ||||||||
| City: | ROANOKE RAPIDS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278704914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2525358005 | ||||||||
| FaxNumber: | 2525358466 | ||||||||
| Practice Location | |||||||||
| Address1: | 250 SMITH CHURCH RD | ||||||||
| Address2: | |||||||||
| City: | ROANOKE RAPIDS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278704914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2525358005 | ||||||||
| FaxNumber: | 2525358466 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2007 | ||||||||
| LastUpdateDate: | 08/13/2020 | ||||||||
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| AuthorizedOfficialLastName: | JENSEN | ||||||||
| AuthorizedOfficialFirstName: | SHERRY | ||||||||
| AuthorizedOfficialMiddleName: | EMERY | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2525358005 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 08/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | H0230 | NC | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
| ID | Type | State | Issuer | Description | 07637 | 01 | NC | BLUE CROSS BS ER PHYS. | OTHER | 58593301 | 01 | MD | BCBS OF MARYLAND | OTHER | 007265 | 01 | NY | EMPIRE BCBS OF NEW YORK | OTHER | 6907637 | 05 | NC | MEDICAID | 8907669 | 05 | NC | MEDICAID | 00242 | 01 | NC | BLUE CROSS BLUE SHIELD NC | OTHER | 3400151 | 05 | NC | MEDICAID | 07669 | 01 | NC | BCBS EKG | OTHER | 00380 | 01 | SC | BCBS OF SOUTH CAROLINA | OTHER | 216203 | 01 | VA | ANTHEM BC BS OF VIRGINIA | OTHER |