Provider Demographics
NPI:1548544984
Name:STATESVILLE HMA MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:STATESVILLE HMA MEDICAL GROUP, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR DIR PROV ENROLLMENT & ONBOARDING
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-3334
Mailing Address - Street 1:4000 MERIDIAN BLVD
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-6325
Mailing Address - Country:US
Mailing Address - Phone:615-465-7230
Mailing Address - Fax:
Practice Address - Street 1:1703 DAVIE AVE
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-3521
Practice Address - Country:US
Practice Address - Phone:704-978-2271
Practice Address - Fax:704-978-2478
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATESVILLE HMA MEDICAL GROUP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-10-04
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2347869Medicare PIN