Provider Demographics
NPI:1518549393
Name:IREDELL PHYSICIAN NETWORK, LLC
Entity Type:Organization
Organization Name:IREDELL PHYSICIAN NETWORK, LLC
Other - Org Name:IREDELL SURGERY AT MOORESVILLE ASC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:D
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-873-5661
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 1:653 BLUEFIELD ROAD
Practice Address - Street 2:SUITE D
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117
Practice Address - Country:US
Practice Address - Phone:704-883-3378
Practice Address - Fax:704-883-3228
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IREDELL PHYSICIAN NETWORK, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-04-22
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical