Provider Demographics
NPI:1952402364
Name:SOUTH IREDELL INTERNAL MEDICINE, PA
Entity Type:Organization
Organization Name:SOUTH IREDELL INTERNAL MEDICINE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:B
Authorized Official - Last Name:BLACKBURN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-664-5131
Mailing Address - Street 1:146 MEDICAL PARK RD STE 106
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-8529
Mailing Address - Country:US
Mailing Address - Phone:704-664-5131
Mailing Address - Fax:704-664-7547
Practice Address - Street 1:146 MEDICAL PARK RD STE 106
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-8529
Practice Address - Country:US
Practice Address - Phone:704-664-5131
Practice Address - Fax:704-664-7547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC29531174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2310110Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER