MEDICARE: STATESVILLE HMA MEDICAL GROUP, LLC

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	207XX0005X	Sports Medicine (Orthopaedic Surgery) Physician
2	207X00000X	Orthopaedic Surgery Physician

General Provider Information

NPI Number	:	1457635898
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STATESVILLE HMA MEDICAL GROUP, LLC

Provider Business Mailing Address
First Line	:	4000 MERIDIAN BLVD
Second Line	:
City	:	FRANKLIN
State	:	TN
Zip	:	37067-6325
Country	:	US
Telephone Number	:	615-465-7230
Fax Number	:

Provider Business Practice Location Address
First Line	:	340 SIGNAL HILL DR
Second Line	:	SUITE A
City	:	STATESVILLE
State	:	NC
Zip	:	28625-4483
Country	:	US
Telephone Number	:	704-873-6065
Fax Number	:	704-873-6059

Authorized Official
Title or Position	:	SR DIR PROV ENROLLMENT & ONBOARDING
Name	:	MRS. JENNIFER L JACKSON
Credential	:
Telephone Number	:	615-465-3334

Provider Enumeration Date	:	10/04/2011
Last Update Date	:	01/14/2022

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