Provider Demographics
NPI:1821079963
Name:STANLY MEDICAL SERVICES
Entity Type:Organization
Organization Name:STANLY MEDICAL SERVICES
Other - Org Name:STANLY PEDIATRIC SERVICES AT LOCUST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:FORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-983-8756
Mailing Address - Street 1:320 YADKIN ST
Mailing Address - Street 2:STE B
Mailing Address - City:ALBEMARLE
Mailing Address - State:NC
Mailing Address - Zip Code:28001-3447
Mailing Address - Country:US
Mailing Address - Phone:704-982-0639
Mailing Address - Fax:704-983-6153
Practice Address - Street 1:103 STANLY PKWY
Practice Address - Street 2:STE A
Practice Address - City:LOCUST
Practice Address - State:NC
Practice Address - Zip Code:28097-7704
Practice Address - Country:US
Practice Address - Phone:704-888-8445
Practice Address - Fax:704-888-8456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89015PKMedicaid