Basic Information
| Provider Information | |||||||||
| NPI: | 1184679441 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ARD | ||||||||
| FirstName: | JAMY | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 602658 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282602658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367162255 | ||||||||
| FaxNumber: | 3367166637 | ||||||||
| Practice Location | |||||||||
| Address1: | 4614 COUNTRY CLUB ROAD | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271043520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367162255 | ||||||||
| FaxNumber: | 3367166637 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 03/27/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 2001-0637 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00103970 | 01 | AL | RAILROAD MEDICARE | OTHER | 89129VJ | 05 | NC | MEDICAID | 051553745 | 05 | AL | MEDICAID |