Provider Demographics
NPI:1417962150
Name:CALDWELL MEMORIAL HOSPITAL, INC
Entity Type:Organization
Organization Name:CALDWELL MEMORIAL HOSPITAL, INC
Other - Org Name:SOUTHFORK MEDICAL PARK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHADOWENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-627-8512
Mailing Address - Street 1:321 MULBERRY ST SW
Mailing Address - Street 2:MEDICAL STAFF SERVICES
Mailing Address - City:LENOIR
Mailing Address - State:NC
Mailing Address - Zip Code:28645-5720
Mailing Address - Country:US
Mailing Address - Phone:828-757-5965
Mailing Address - Fax:828-757-5104
Practice Address - Street 1:1731 CONNELLY SPRINGS RD
Practice Address - Street 2:
Practice Address - City:LENOIR
Practice Address - State:NC
Practice Address - Zip Code:28645-7827
Practice Address - Country:US
Practice Address - Phone:828-757-6300
Practice Address - Fax:828-757-6324
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CALDWELL MEMORIAL HOSPITAL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-30
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC790118NMedicaid
NC790118NMedicaid
NC790118NMedicaid
NCCG4760OtherRR MCR