Provider Demographics
NPI:1013291442
Name:STATESVILLE HMA MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:STATESVILLE HMA MEDICAL GROUP, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SIR DIR PROV ENROLLMENT & ONBOARDIN
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:615-465-7230
Mailing Address - Fax:
Practice Address - Street 1:1424 FERN CREEK DR
Practice Address - Street 2:SUITE B
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625-9376
Practice Address - Country:US
Practice Address - Phone:704-662-9870
Practice Address - Fax:704-662-9788
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATESVILLE HMA MEDICAL GROUP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-10-04
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2347869Medicare PIN