Provider Demographics
NPI:1477648731
Name:VIDANT MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:VIDANT MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:S
Authorized Official - Last Name:HUGHES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-847-4582
Mailing Address - Street 1:PO BOX 8423
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27835-8423
Mailing Address - Country:US
Mailing Address - Phone:252-847-2181
Mailing Address - Fax:252-847-2213
Practice Address - Street 1:2100 STANTONSBURG RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-2818
Practice Address - Country:US
Practice Address - Phone:252-847-2181
Practice Address - Fax:252-847-2213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5912190Medicaid
NC018YMOtherBLUE CROSS BLUE SHIELD
NC5906333Medicaid
NC5906333Medicaid
NC5912190Medicaid
NC=========OtherMEDCOST