Provider Demographics
NPI:1548796584
Name:STATESVILLE HMA MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:STATESVILLE HMA MEDICAL GROUP, LLC
Other - Org Name:DAVIS MEDICAL GROUP FAMILY PRACTICE STONY POINT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR DIR PROV ENROLLMENT & ONBAORDING
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-3334
Mailing Address - Street 1:4000 MERIDIAN BLVD
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-6325
Mailing Address - Country:US
Mailing Address - Phone:615-465-7230
Mailing Address - Fax:
Practice Address - Street 1:35 RURITAN PARK RD
Practice Address - Street 2:
Practice Address - City:STONY POINT
Practice Address - State:NC
Practice Address - Zip Code:28678-8928
Practice Address - Country:US
Practice Address - Phone:704-585-9373
Practice Address - Fax:704-585-9397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-11
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101815207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty