Provider Demographics
NPI:1487629978
Name:PERSON MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:PERSON MEMORIAL HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:C
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-599-2121
Mailing Address - Street 1:615 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ROXBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27573-4629
Mailing Address - Country:US
Mailing Address - Phone:336-599-2121
Mailing Address - Fax:
Practice Address - Street 1:615 RIDGE RD
Practice Address - Street 2:
Practice Address - City:ROXBORO
Practice Address - State:NC
Practice Address - Zip Code:27573-4629
Practice Address - Country:US
Practice Address - Phone:336-599-2121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCH0066282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3400159Medicaid
NC890764BMedicaid
NC00423OtherBLUE CROSS PROVIDER #
NC0764BOtherBLUE CROSS PROF PROV #
NC8000316Medicaid
NC=========OtherFEDERAL TAX ID NUMBER
NC0764BOtherBLUE CROSS PROF PROV #
NC340159Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
NC3400159Medicaid