Basic Information
| Provider Information | |||||||||
| NPI: | 1750392825 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CALDWELL MEMORIAL HOSPITAL INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | BROYHILL FAMILY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 710 | ||||||||
| Address2: | |||||||||
| City: | LENOIR | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286450710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8287575070 | ||||||||
| FaxNumber: | 8287577882 | ||||||||
| Practice Location | |||||||||
| Address1: | 2651 MORGANTON BLVD SW | ||||||||
| Address2: | |||||||||
| City: | LENOIR | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286458183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8287592000 | ||||||||
| FaxNumber: | 8287578968 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 12/14/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GARDNER | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | VP/ CFO/CCO | ||||||||
| AuthorizedOfficialTelephone: | 8287575221 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BROYHILL FAMILY HEALTH CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 015E9 | 01 | NC | BCBS | OTHER | 89015E9 | 05 | NC | MEDICAID |