Healthcare Provider Details

I. General information

NPI: 1699838912
Provider Name (Legal Business Name): IREDELL MEMORIAL HOSPITAL, INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 08/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

557 BROOKDALE DR
STATESVILLE NC
28677-4107
US

IV. Provider business mailing address

557 BROOKDALE DR
STATESVILLE NC
28677-4107
US

V. Phone/Fax

Practice location:
  • Phone: 704-873-5661
  • Fax:
Mailing address:
  • Phone: 704-873-5661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number003515
License Number StateNC

VIII. Authorized Official

Name: MR. ED RUSH
Title or Position: PRESIDENT
Credential:
Phone: 704-873-5661