Provider Demographics
NPI:1811093693
Name:DIVERSIFIED MEDICAL, PLLC
Entity type:Organization
Organization Name:DIVERSIFIED MEDICAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:VAN NESS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:866-434-8633
Mailing Address - Street 1:200 N HARBOR PL
Mailing Address - Street 2:SUITES B/C
Mailing Address - City:DAVIDSON
Mailing Address - State:NC
Mailing Address - Zip Code:28036-7918
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 N HARBOR PL
Practice Address - Street 2:SUITES B/C
Practice Address - City:DAVIDSON
Practice Address - State:NC
Practice Address - Zip Code:28036-7918
Practice Address - Country:US
Practice Address - Phone:866-434-8633
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA049747208100000X
AL00023727208100000X
PAMD 073346-L208100000X
NY237905208100000X
IN01061499A208100000X
MDD0063862208100000X
SCTL28503208100000X
KY33150208100000X
OH35 087813208100000X
VA0101239263208100000X
FLME 95839208100000X
IL208100000X
NC208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty