NPIMap

Organization Active NPI

Mooresville PPM, LLC

  • Interventional Cardiology Physician
  • Statesville, NC
National Provider Identifier
1003567082
Registry record updated Jan 12, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Interventional Cardiology PhysicianTaxonomy code 207RI0011X
Legal business name
MOORESVILLE PPM, LLC
Practice address
1424 Fern Creek Dr Ste D
Statesville, NC 28625-9376
Phone
(704) 878-2058
Fax
(704) 872-6576
NPI assigned
Jan 12, 2022
Organization subpart
Yes
Parent organization
MOORESVILLE PPM, LLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jan 12, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Jennifer L Jackson
Title
Sr Dir Prov Enroll & Onboarding
Phone
(615) 465-3334

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Interventional Cardiology PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207RI0011X Primary

Addresses

Primary practice location

1424 Fern Creek Dr Ste D
Statesville, NC 28625-9376

Mailing address

PO Box 689022
Franklin, TN 37068-9022
Phone (615) 465-7230

Other names 1

  • Lake Norman Medical Group Heart & Vascular Statesville Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Mooresville PPM LLC7 organizations share this tax ID, including this one
Part of
Mooresville PPM LLC

Other organizations with this tax ID 6

Organizations that report the same tax identification number in the National Provider Directory.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1641945600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1641945600000",
    "number": "1003567082",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 689022",
            "city": "FRANKLIN",
            "state": "TN",
            "postal_code": "370689022",
            "telephone_number": "615-465-7230",
            "fax_number": "615-628-6677"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1424 FERN CREEK DR STE D",
            "city": "STATESVILLE",
            "state": "NC",
            "postal_code": "286259376",
            "telephone_number": "704-878-2058",
            "fax_number": "704-872-6576"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MOORESVILLE PPM, LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "MOORESVILLE PPM, LLC",
        "enumeration_date": "2022-01-12",
        "last_updated": "2022-01-12",
        "certification_date": "2022-01-12",
        "status": "A",
        "authorized_official_last_name": "JACKSON",
        "authorized_official_first_name": "JENNIFER",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "SR DIR PROV ENROLL & ONBOARDING",
        "authorized_official_telephone_number": "615-465-3334"
    },
    "taxonomies": [
        {
            "code": "207RI0011X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Internal Medicine, Interventional Cardiology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Lake Norman Medical Group Heart & Vascular Statesville",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Statesville, NC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 12, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.