Provider Demographics
NPI:1255417358
Name:MOUNTAIN LAUREL INTERNAL MEDICINE,PA
Entity type:Organization
Organization Name:MOUNTAIN LAUREL INTERNAL MEDICINE,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:828-733-0270
Mailing Address - Street 1:PO BOX 1045
Mailing Address - Street 2:
Mailing Address - City:LINVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28646-1045
Mailing Address - Country:US
Mailing Address - Phone:828-733-0270
Mailing Address - Fax:828-733-9271
Practice Address - Street 1:2139 LINVILLE FALLS HWY
Practice Address - Street 2:
Practice Address - City:LINVILLE
Practice Address - State:NC
Practice Address - Zip Code:28646
Practice Address - Country:US
Practice Address - Phone:828-733-0270
Practice Address - Fax:828-733-9271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC36648261QP2300X
207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC=========OtherTAX ID#
NC1255417358Medicare PIN
NC2339847Medicare PIN