=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194219931
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTEGRATED CARE OF GREATER HICKORY, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2018
-----------------------------------------------------
Last Update Date | 06/15/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1228 N FLINT ST
-----------------------------------------------------
City | LINCOLNTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28092-5239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-322-5915
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1228 N FLINT ST
-----------------------------------------------------
City | LINCOLNTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28092-5239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-322-5915
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ELBERT ANDREW RUDISILL
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 828-322-5915
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207QA0401X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2084A0401X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Psychiatry & Neurology) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------