=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235125378
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HICKORY INTERNAL MEDICINE, HYPERTENSION & RENAL ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 50 13TH AVE NE SUITE 2A
-----------------------------------------------------
City | HICKORY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28601-3748
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-322-3541
-----------------------------------------------------
Fax | 828-324-7862
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 50 13TH AVE NE SUITE 2A
-----------------------------------------------------
City | HICKORY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28601-3748
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-322-3541
-----------------------------------------------------
Fax | 828-324-7862
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. HENRY IGDAL
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 828-322-3541
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 173000000X
-----------------------------------------------------
Taxonomy Name | Legal Medicine
-----------------------------------------------------
License Number | 35141
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------