Provider Demographics
NPI:1568833705
Name:MISSION MEDICAL ASSOCIATES, INC.
Entity Type:Organization
Organization Name:MISSION MEDICAL ASSOCIATES, INC.
Other - Org Name:MMA PSYCHIATRIC SERVICES - PEDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VP
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:
Authorized Official - Last Name:HOGGARD-GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:828-213-1111
Mailing Address - Street 1:PO BOX 602373
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2373
Mailing Address - Country:US
Mailing Address - Phone:828-213-1500
Mailing Address - Fax:828-651-6570
Practice Address - Street 1:387 US 70 W
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:NC
Practice Address - Zip Code:28752-6202
Practice Address - Country:US
Practice Address - Phone:828-213-4502
Practice Address - Fax:828-213-4540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-14
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208000000X
NC2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty