Provider Demographics
NPI:1114005261
Name:MID-STATE HEALTH SYSTEMS, INC
Entity Type:Organization
Organization Name:MID-STATE HEALTH SYSTEMS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SERA
Authorized Official - Middle Name:W
Authorized Official - Last Name:GILMORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-484-3717
Mailing Address - Street 1:PO BOX 65262
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28306
Mailing Address - Country:US
Mailing Address - Phone:910-484-3717
Mailing Address - Fax:
Practice Address - Street 1:3721 LEGION RD
Practice Address - Street 2:
Practice Address - City:HOPE MILLS
Practice Address - State:NC
Practice Address - Zip Code:28348-8411
Practice Address - Country:US
Practice Address - Phone:910-484-3717
Practice Address - Fax:910-484-1315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-026-199251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300773Medicaid