Provider Demographics
NPI:1639318751
Name:IREDELL PHYSICIAN NETWORK LLC
Entity type:Organization
Organization Name:IREDELL PHYSICIAN NETWORK LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:PURCELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-878-4569
Mailing Address - Street 1:PO BOX 25867
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27114-5867
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:955 WEST MEMORIAL HIGHWAY
Practice Address - Street 2:
Practice Address - City:HARMONY
Practice Address - State:NC
Practice Address - Zip Code:28634-9352
Practice Address - Country:US
Practice Address - Phone:704-878-4569
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IREDELL PHYSICIAN NETWORK LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-02-12
Last Update Date:2010-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5911498Medicaid