MEDICARE: BARIUM SPRINGS HOME FOR CHILDREN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician		NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1235312372
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BARIUM SPRINGS HOME FOR CHILDREN

Provider Business Mailing Address
First Line	:	156 FRAZIER LOOP
Second Line	:
City	:	STATESVILLE
State	:	NC
Zip	:	28677-6238
Country	:	US
Telephone Number	:	704-873-1011
Fax Number	:	704-832-2253

Provider Business Practice Location Address
First Line	:	135 BURROUGHS LOOP
Second Line	:
City	:	STATESVILLE
State	:	NC
Zip	:	28677-6238
Country	:	US
Telephone Number	:	701-873-1011
Fax Number	:	704-832-2253

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JOHN KOPPELMEYER
Credential	:
Telephone Number	:	704-873-1011

Provider Enumeration Date	:	12/12/2007
Last Update Date	:	12/12/2007

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1386911451 — SHANNON GANTT SHORE LCSW
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Practice Fax:

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