Provider Demographics
NPI:1730125238
Name:HICKORY FAMILY PRACTICE ASSOCIATES, PA
Entity Type:Organization
Organization Name:HICKORY FAMILY PRACTICE ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:EARL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:828-328-2941
Mailing Address - Street 1:52 12TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28601-2695
Mailing Address - Country:US
Mailing Address - Phone:828-328-2941
Mailing Address - Fax:828-328-4049
Practice Address - Street 1:52 12TH AVE NE
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28601-2695
Practice Address - Country:US
Practice Address - Phone:828-328-2941
Practice Address - Fax:828-328-4049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC40313207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8901561Medicaid
NC8901561Medicaid