Healthcare Provider Details

I. General information

NPI: 1922752260
Provider Name (Legal Business Name): IREDELL PHYSICIAN NETWORK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2022
Last Update Date: 02/07/2022
Certification Date: 02/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

766 HARTNESS RD STE A
STATESVILLE NC
28677-3485
US

IV. Provider business mailing address

PO BOX 896199
CHARLOTTE NC
28289-6199
US

V. Phone/Fax

Practice location:
  • Phone: 704-380-3620
  • Fax: 704-380-3623
Mailing address:
  • Phone: 833-936-1364
  • Fax: 312-277-5144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: CARLA D JOHNSON
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 704-873-5661