Basic Information
| Provider Information | |||||||||
| NPI: | 1548230204 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IREDELL MEMORIAL HOSPITAL, INCORPORATED | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | IMH PROFESSIONAL CRNA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 557 BROOKDALE DR | ||||||||
| Address2: | |||||||||
| City: | STATESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28677 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048735661 | ||||||||
| FaxNumber: | 7048784611 | ||||||||
| Practice Location | |||||||||
| Address1: | 557 BROOKDALE DR | ||||||||
| Address2: | |||||||||
| City: | STATESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28677 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048735661 | ||||||||
| FaxNumber: | 7048784611 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2006 | ||||||||
| LastUpdateDate: | 08/18/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RUSH | ||||||||
| AuthorizedOfficialFirstName: | ED | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7048735661 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | IREDELL MEMORIAL HOSPITAL, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 8000167 | 05 | NC | MEDICAID |