Provider Demographics
NPI:1437452513
Name:ST LUKES PHYSICIAN NETWORK, INC.
Entity Type:Organization
Organization Name:ST LUKES PHYSICIAN NETWORK, INC.
Other - Org Name:FOOTHILLS MEDICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:WEATHERS
Authorized Official - Last Name:PRESNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-894-0954
Mailing Address - Street 1:PO BOX 602527
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2527
Mailing Address - Country:US
Mailing Address - Phone:828-894-5627
Mailing Address - Fax:
Practice Address - Street 1:801 W MILLS ST
Practice Address - Street 2:SUITE C
Practice Address - City:COLUMBUS
Practice Address - State:NC
Practice Address - Zip Code:28722-8494
Practice Address - Country:US
Practice Address - Phone:828-894-5627
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST LUKES PHYSICIAN NETWORK INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-12-13
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1437452513Medicaid
NC5917245Medicaid
NC5917245Medicaid