Provider Demographics
NPI:1124003934
Name:FAMILY MEDICINE OF HARRELLSVILLE
Entity Type:Organization
Organization Name:FAMILY MEDICINE OF HARRELLSVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:GADDY
Authorized Official - Middle Name:MATHESON
Authorized Official - Last Name:LASSITER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:252-356-6544
Mailing Address - Street 1:103 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HARRELLSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27942-9201
Mailing Address - Country:US
Mailing Address - Phone:252-356-6544
Mailing Address - Fax:252-356-9907
Practice Address - Street 1:103 E MAIN ST
Practice Address - Street 2:
Practice Address - City:HARRELLSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27942-9201
Practice Address - Country:US
Practice Address - Phone:252-356-6544
Practice Address - Fax:252-356-9907
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891216WMedicaid
NC1216WOtherBC/BS INDIVIDUAL #
NC2277138DMedicare ID - Type UnspecifiedINDIVIDUAL #
NC22336538Medicare ID - Type UnspecifiedGROUP #
NC891216WMedicaid