Provider Demographics
NPI:1285849760
Name:STATESVILLE HMA, LLC
Entity Type:Organization
Organization Name:STATESVILLE HMA, LLC
Other - Org Name:DAVIS REGIONAL MED CENTER CRNA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VP AND GENERAL COUNSEL
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:PARRY
Authorized Official - Suffix:
Authorized Official - Credentials:ESQ
Authorized Official - Phone:239-598-3176
Mailing Address - Street 1:218 OLD MOCKSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28625-1930
Mailing Address - Country:US
Mailing Address - Phone:704-838-7102
Mailing Address - Fax:
Practice Address - Street 1:218 OLD MOCKSVILLE RD
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625-1930
Practice Address - Country:US
Practice Address - Phone:704-838-7102
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS8000282Medicaid
MS8000282Medicaid