Provider Demographics
NPI:1477805166
Name:IREDELL PHYSICIAN NETWORK, LLC
Entity Type:Organization
Organization Name:IREDELL PHYSICIAN NETWORK, LLC
Other - Org Name:RUBY GRIMM, M.D.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:
Authorized Official - Last Name:HELES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-340-0396
Mailing Address - Street 1:PO BOX 896199
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28289-6199
Mailing Address - Country:US
Mailing Address - Phone:833-936-1364
Mailing Address - Fax:605-942-7505
Practice Address - Street 1:738 BRYANT ST
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-4189
Practice Address - Country:US
Practice Address - Phone:704-873-2219
Practice Address - Fax:704-873-1379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-05
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty