Basic Information
| Provider Information | |||||||||
| NPI: | 1124305792 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CATAWBA VALLEY MEDICAL GROUP, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CATAWBA VALLEY FAMILY MEDICINE - MAIDEN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 137 ISLAND FORD RD | ||||||||
| Address2: | |||||||||
| City: | MAIDEN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286508735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8284282446 | ||||||||
| FaxNumber: | 8284288226 | ||||||||
| Practice Location | |||||||||
| Address1: | 137 ISLAND FORD RD | ||||||||
| Address2: | |||||||||
| City: | MAIDEN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286508735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8284282446 | ||||||||
| FaxNumber: | 8284288226 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2011 | ||||||||
| LastUpdateDate: | 04/25/2022 | ||||||||
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| AuthorizedOfficialLastName: | CREWS | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | VP OF FINANCE/CFO | ||||||||
| AuthorizedOfficialTelephone: | 8283263806 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CATAWBA VALLEY MEDICAL CENTER | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 026CW | 01 | NC | NC BCBS | OTHER | 1124305792 | 05 | NC | MEDICAID |