Basic Information
| Provider Information | |||||||||
| NPI: | 1306138714 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CATAWBA VALLEY MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NEONATAL PRACTITIONERS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 810 FAIRGROVE CHURCH RD | ||||||||
| Address2: | |||||||||
| City: | HICKORY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286029617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8283263809 | ||||||||
| FaxNumber: | 8283263371 | ||||||||
| Practice Location | |||||||||
| Address1: | 810 FAIRGROVE CHURCH RD | ||||||||
| Address2: | |||||||||
| City: | HICKORY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286029617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8283263809 | ||||||||
| FaxNumber: | 8283263371 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2011 | ||||||||
| LastUpdateDate: | 11/10/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CREWS | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | VP OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 8283263806 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WN0002X | Y | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Neonatal Intensive Care |
ID Information
| ID | Type | State | Issuer | Description | 1306138714 | 05 | NC | MEDICAID |