Provider Demographics
NPI:1437330644
Name:STOKES REYNOLDS MEMORIAL HOSPITAL, INC.
Entity Type:Organization
Organization Name:STOKES REYNOLDS MEMORIAL HOSPITAL, INC.
Other - Org Name:STOKES MEDICAL ASSOCIATES-PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:P
Authorized Official - Last Name:TILLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-593-5314
Mailing Address - Street 1:PO BOX 10
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:NC
Mailing Address - Zip Code:27016-0010
Mailing Address - Country:US
Mailing Address - Phone:336-593-5354
Mailing Address - Fax:336-593-5331
Practice Address - Street 1:1030 HOSPICE DRIVE
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:NC
Practice Address - Zip Code:27016-1030
Practice Address - Country:US
Practice Address - Phone:336-593-5354
Practice Address - Fax:336-593-5331
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STOKES REYNOLDS MEMORIAL HOSPITAL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-15
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC235111FOtherMEDICARE PTAN GROUP#
NC5908390Medicaid