Basic Information
| Provider Information | |||||||||
| NPI: | 1700837903 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CATAWBA VALLEY MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | MAIDEN FAMILY PRACTICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 137 ISLAND FORD RD | ||||||||
| Address2: | |||||||||
| City: | MAIDEN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286508735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8283263809 | ||||||||
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| Practice Location | |||||||||
| Address1: | 137 ISLAND FORD RD | ||||||||
| Address2: | |||||||||
| City: | MAIDEN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286508735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8283263809 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 12/18/2007 | ||||||||
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| AuthorizedOfficialLastName: | BOONE | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | VP OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 8283263809 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0206W | 01 | NC | MAIDEN BCBS | OTHER | 890206W | 05 | NC | MEDICAID |