Provider Demographics
NPI:1750125035
Name:VIDANT MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:VIDANT MEDICAL GROUP, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP, MANAGED CARE CVO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:RONALD
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-847-6114
Mailing Address - Street 1:210 SMITH CHURCH RD STE B
Mailing Address - Street 2:
Mailing Address - City:ROANOKE RAPIDS
Mailing Address - State:NC
Mailing Address - Zip Code:27870-4942
Mailing Address - Country:US
Mailing Address - Phone:252-847-2376
Mailing Address - Fax:252-847-7337
Practice Address - Street 1:210 SMITH CHURCH RD STE B
Practice Address - Street 2:
Practice Address - City:ROANOKE RAPIDS
Practice Address - State:NC
Practice Address - Zip Code:27870-4942
Practice Address - Country:US
Practice Address - Phone:252-847-2376
Practice Address - Fax:252-847-7337
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VIDANT MEDICAL GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-06-21
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0404XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Cardiac Facilities
No163WC3500XNursing Service ProvidersRegistered NurseCardiac RehabilitationGroup - Multi-Specialty