Provider Demographics
NPI: | 1700028982 |
---|---|
Name: | MOORESVILLE PPM LLC |
Entity Type: | Organization |
Organization Name: | MOORESVILLE PPM LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | SR DIR PROV ENROLLMENT & ONBOARDING |
Authorized Official - Prefix: | MRS |
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: | 615-465-7000 |
Mailing Address - Fax: | 615-628-6877 |
Practice Address - Street 1: | 131 MEDICAL PARK RD |
Practice Address - Street 2: | SUITE 302 |
Practice Address - City: | MOORESVILLE |
Practice Address - State: | NC |
Practice Address - Zip Code: | 28117-8522 |
Practice Address - Country: | US |
Practice Address - Phone: | 704-660-4750 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | Yes |
Parent Organization LBN: | MOORESVILLE PPM LLC |
Parent Organization TIN: | <UNAVAIL> |
Enumeration Date: | 2009-04-02 |
Last Update Date: | 2022-01-14 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
207Q00000X, 207QS0010X, 207R00000X, 207XS0106X, 207XS0117X, 207XX0005X, 208000000X, 2080N0001X, 208100000X, 208600000X, 363A00000X, 363L00000X | ||
NC | 22538 | 207X00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 207QS0010X | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | Group - Multi-Specialty |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
No | 207XS0106X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | Group - Multi-Specialty |
No | 207XS0117X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine | Group - Multi-Specialty |
No | 207XX0005X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | Group - Multi-Specialty |
No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
No | 2080N0001X | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine | Group - Multi-Specialty |
No | 208100000X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Group - Multi-Specialty | |
No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NC | 2347341 | Medicare PIN |