Healthcare Provider Details

I. General information

NPI: 1750362802
Provider Name (Legal Business Name): STANLY MEDICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 07/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

835 ALBEMARLE RD
TROY NC
27371-8682
US

IV. Provider business mailing address

320 YADKIN ST SUITE B
ALBEMARLE NC
28001-3447
US

V. Phone/Fax

Practice location:
  • Phone: 910-572-2309
  • Fax: 910-572-3655
Mailing address:
  • Phone: 704-983-7320
  • Fax: 704-983-6153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0276A
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerBCBS
# 2
Identifier890276A
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name: MARINDY BOST HARRIS
Title or Position: MANAGER REVENUE CYCLE
Credential:
Phone: 704-983-7320