Provider Demographics
NPI:1235198482
Name:TALL OAKS FAMILY PRACTICE
Entity Type:Organization
Organization Name:TALL OAKS FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PROVIDER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:B
Authorized Official - Last Name:VANHOY
Authorized Official - Suffix:
Authorized Official - Credentials:PAC
Authorized Official - Phone:704-658-0011
Mailing Address - Street 1:798 OAK RIDGE FARM RD.
Mailing Address - Street 2:SUITE A
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28115
Mailing Address - Country:US
Mailing Address - Phone:704-658-0011
Mailing Address - Fax:704-658-0012
Practice Address - Street 1:798 OAK RIDGE FARM RD.
Practice Address - Street 2:SUITE A
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28115
Practice Address - Country:US
Practice Address - Phone:704-658-0011
Practice Address - Fax:704-658-0012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-17
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101555207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891108XMedicaid
NC012NEOtherBCBS ID#
NC89012NEMedicaid
NC89012NEMedicaid
NC2344836Medicare UPIN
NCS76844Medicare UPIN
NC891108XMedicaid