Provider Demographics
NPI:1114704558
Name:IREDELL PHYSICIAN NETWORK, LLC
Entity Type:Organization
Organization Name:IREDELL PHYSICIAN NETWORK, LLC
Other - Org Name:STATESVILLE INTERNAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:JOANIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:COCHRAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-306-9755
Mailing Address - Street 1:PO BOX 896199
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28289-6199
Mailing Address - Country:US
Mailing Address - Phone:844-652-0611
Mailing Address - Fax:
Practice Address - Street 1:1540 E BROAD ST STE B
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625-4302
Practice Address - Country:US
Practice Address - Phone:704-253-4085
Practice Address - Fax:704-253-4085
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IREDELL PHYSICIAN NETWORK, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty