Provider Demographics
NPI:1558544957
Name:HOLLY RIDGE HEALTHCARE PA
Entity Type:Organization
Organization Name:HOLLY RIDGE HEALTHCARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:PRIDGEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-329-1707
Mailing Address - Street 1:119 HOLLY ST
Mailing Address - Street 2:
Mailing Address - City:HOLLY RIDGE
Mailing Address - State:NC
Mailing Address - Zip Code:28445-7898
Mailing Address - Country:US
Mailing Address - Phone:910-329-1707
Mailing Address - Fax:910-329-1716
Practice Address - Street 1:119 HOLLY ST
Practice Address - Street 2:
Practice Address - City:HOLLY RIDGE
Practice Address - State:NC
Practice Address - Zip Code:28445-7898
Practice Address - Country:US
Practice Address - Phone:910-329-1707
Practice Address - Fax:910-329-1716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-10
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC29495207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89012R8Medicaid
209723XMedicare PIN