Basic Information
Provider Information | |||||||||
NPI: | 1699838912 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | IREDELL MEMORIAL HOSPITAL, INCORPORATED | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | IMH DIABETES CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 557 BROOKDALE DR | ||||||||
Address2: |   | ||||||||
City: | STATESVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 286774107 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7048735661 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 557 BROOKDALE DR | ||||||||
Address2: |   | ||||||||
City: | STATESVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 286774107 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7048735661 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/18/2006 | ||||||||
LastUpdateDate: | 08/03/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RUSH | ||||||||
AuthorizedOfficialFirstName: | ED | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 7048735661 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | IREDELL MEMORIAL HOSPITAL, INCORPORATED | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WD0400X | 003515 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Diabetes Educator |
No ID Information.