Provider Demographics
NPI:1487840427
Name:IREDELL PHYSICIAN NETWORK LLC
Entity Type:Organization
Organization Name:IREDELL PHYSICIAN NETWORK LLC
Other - Org Name:YOUNG FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:PURCELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-878-4569
Mailing Address - Street 1:PO BOX 25867
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27114-5867
Mailing Address - Country:US
Mailing Address - Phone:704-924-7992
Mailing Address - Fax:704-924-7950
Practice Address - Street 1:774 HARTNESS RD
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-3376
Practice Address - Country:US
Practice Address - Phone:704-924-7992
Practice Address - Fax:704-924-7950
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IREDELL PHYSICIAN NETWORK LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-24
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC96-00787207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5908193Medicaid