Provider Demographics
NPI:1942942842
Name:STATESVILLE HMA MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:STATESVILLE HMA MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:BALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-660-4524
Mailing Address - Street 1:131 MEDICAL PARK RD STE 302
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-8525
Mailing Address - Country:US
Mailing Address - Phone:704-660-4524
Mailing Address - Fax:
Practice Address - Street 1:1102 YADKINVILLE RD STE A-B
Practice Address - Street 2:
Practice Address - City:MOCKSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27028-2037
Practice Address - Country:US
Practice Address - Phone:704-660-4693
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATESVILLE HMA MEDICAL GROUP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-04-11
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty