Provider Demographics
NPI:1275069858
Name:STATESVILLE HMA MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:STATESVILLE HMA MEDICAL GROUP LLC
Other - Org Name:DAVIS MEDICAL GROUP OBSTETRICS & GYNECOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR DIR PROV ENROLLMENT & ONBOARDING
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-3334
Mailing Address - Street 1:4000 MERIDIAN BLVD
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-6325
Mailing Address - Country:US
Mailing Address - Phone:615-465-7230
Mailing Address - Fax:
Practice Address - Street 1:555 KITCHINGS DR
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-3576
Practice Address - Country:US
Practice Address - Phone:704-872-7294
Practice Address - Fax:704-872-4078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-03
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC28478207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty