MEDICARE: MOORESVILLE PPM 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	208600000X	Surgery Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1598032849
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOORESVILLE PPM 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	:	123 PROFESSIONAL PARK DR
Second Line	:	SUITE 200
City	:	MOORESVILLE
State	:	NC
Zip	:	28117-5524
Country	:	US
Telephone Number	:	704-663-0006
Fax Number	:	704-663-5224

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

Provider Enumeration Date	:	11/30/2011
Last Update Date	:	01/14/2022

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Directions to “MOORESVILLE PPM LLC ” Practice Location

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