Provider Demographics
NPI:1720246341
Name:IREDELL PHYSICIAN NETWORK LLC
Entity Type:Organization
Organization Name:IREDELL PHYSICIAN NETWORK LLC
Other - Org Name:IREDELL ORTHOPAEDIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:
Authorized Official - Last Name:HELES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-340-0396
Mailing Address - Street 1:PO BOX 896199
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28289-6199
Mailing Address - Country:US
Mailing Address - Phone:833-936-1364
Mailing Address - Fax:605-942-7505
Practice Address - Street 1:774 HARTNESS RD
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-3376
Practice Address - Country:US
Practice Address - Phone:704-768-3030
Practice Address - Fax:704-768-3025
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IREDELL PHYSICIAN NETWORK LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-30
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2006 01184207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5950130Medicaid