Basic Information
| Provider Information | |||||||||
| NPI: | 1306899950 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CATAWBA VALLEY MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | FAIRGROVE PRIMARY HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3412 GRAYSTONE PL | ||||||||
| Address2: | |||||||||
| City: | CONOVER | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286138200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8283263809 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3412 GRAYSTONE PL | ||||||||
| Address2: | |||||||||
| City: | CONOVER | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286138200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8283263809 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 11/10/2021 | ||||||||
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| 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 | 207VG0400X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 014GH | 01 | NC | BCBS PROVIDER NUMBER | OTHER | 8700485 | 01 | NC | MEDICAID-HIV | OTHER | 89014GH | 05 | NC | MEDICAID |