=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710089164
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRANVILLE HEALTH SYSTEM
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/05/2006
-----------------------------------------------------
Last Update Date | 10/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 102 PROFESSIONAL PARK STE A
-----------------------------------------------------
City | OXFORD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27565-2554
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-690-3217
-----------------------------------------------------
Fax | 919-690-3218
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 947
-----------------------------------------------------
City | OXFORD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27565-0947
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-690-3000
-----------------------------------------------------
Fax | 919-603-1097
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | JAMIE PURVIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 919-690-3237
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0804X
-----------------------------------------------------
Taxonomy Name | Child & Adolescent Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------