MEDICARE: HOLLY RIDGE HEALTHCARE PA

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	207Q00000X	Family Medicine Physician	29495	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	:	1558544957
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOLLY RIDGE HEALTHCARE PA

Provider Business Mailing Address
First Line	:	119 HOLLY ST
Second Line	:
City	:	HOLLY RIDGE
State	:	NC
Zip	:	28445-7898
Country	:	US
Telephone Number	:	910-329-1707
Fax Number	:	910-329-1716

Provider Business Practice Location Address
First Line	:	119 HOLLY ST
Second Line	:
City	:	HOLLY RIDGE
State	:	NC
Zip	:	28445-7898
Country	:	US
Telephone Number	:	910-329-1707
Fax Number	:	910-329-1716

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. JAMES HENRY PRIDGEN
Credential	:	M.D.
Telephone Number	:	910-329-1707

Provider Enumeration Date	:	12/10/2007
Last Update Date	:	03/28/2019

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