MEDICARE: HEALTHSTAT ON-SITE CLINIC/MEDECO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2083P0500X	Preventive Medicine/Occupational Environmental Medicine Physician

General Provider Information

NPI Number	:	1083958953
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEALTHSTAT ON-SITE CLINIC/MEDECO

Provider Business Mailing Address
First Line	:	4651 CHARLOTTE PARK DR
Second Line	:	SUITE 300
City	:	CHARLOTTE
State	:	NC
Zip	:	28217-1956
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3625 ALLEGHANY DR
Second Line	:
City	:	SALEM
State	:	VA
Zip	:	24153-1977
Country	:	US
Telephone Number	:	540-380-1618
Fax Number	:

Authorized Official
Title or Position	:	COO
Name	:	MR. WARREN HUTTON
Credential	:
Telephone Number	:	704-529-6161

Provider Enumeration Date	:	11/16/2012
Last Update Date	:	11/16/2012

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