NPIMap

Organization Active NPI

Iredell Physician Network LLC

Doing business as Statesville Family Practice

  • Family Medicine Physician
  • Statesville, NC
National Provider Identifier
1053360180
Registry record updated Oct 1, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
IREDELL PHYSICIAN NETWORK LLC
Doing business as
Statesville Family Practice
Practice address
310 Davie Ave
Statesville, NC 28677-5319
Phone
(704) 873-3269
Fax
(704) 871-8159
NPI assigned
May 8, 2006
Last updated
Oct 1, 2024By the provider in NPPES
Organization subpart
Yes
Parent organization
IREDELL PHYSICIAN NETWORK LLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Oct 1, 2024

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

Authorized official

Name
Carla Johnson
Title
Director of Operations
Phone
(704) 873-5661

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207Q00000X Primary

Addresses

Primary practice location

310 Davie Ave
Statesville, NC 28677-5319

Mailing address

PO Box 896199
Charlotte, NC 28289-6199
Phone (833) 936-1364

Other identifiers 1

IdentifierTypeStateIssuer
8902748MedicaidNC

Other names 1

  • Statesville Family Practice Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NC

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20090219000651 NC Part B Supplier - Clinic/Group Practice 0749345007 Receives reassigned benefits from 139 practitioners
39 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Statesville, NC; Taylorsville, NC; Troutman, NC; Hickory, NC; Harmony, NC; Mooresville, NC

Other NPIs on the same Medicare enrollment 39

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 39

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
34D0247344Statesville Family Practice310 Davie Ave, Statesville, NC 28677Certificate of waiverAug 31, 2026

National Provider Directory

National Provider Directory
Part of
Iredell Internal Medicine

Locations

1217 Davie Ave
Statesville, NC 28677
Phone (704) 838-7080

310 Davie Ave
Statesville, NC 28677
Phone (704) 873-3269

NPI Registry JSON

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

{
    "created_epoch": "1147046400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1727740800000",
    "number": "1053360180",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 896199",
            "city": "CHARLOTTE",
            "state": "NC",
            "postal_code": "282896199",
            "telephone_number": "833-936-1364",
            "fax_number": "605-942-7505"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "310 DAVIE AVE",
            "city": "STATESVILLE",
            "state": "NC",
            "postal_code": "286775319",
            "telephone_number": "704-873-3269",
            "fax_number": "704-871-8159"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "IREDELL PHYSICIAN NETWORK LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "IREDELL PHYSICIAN NETWORK LLC",
        "enumeration_date": "2006-05-08",
        "last_updated": "2024-10-01",
        "certification_date": "2024-10-01",
        "status": "A",
        "authorized_official_last_name": "JOHNSON",
        "authorized_official_first_name": "CARLA",
        "authorized_official_title_or_position": "DIRECTOR OF OPERATIONS",
        "authorized_official_telephone_number": "704-873-5661"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "8902748",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Statesville Family Practice",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Statesville Family Practice",
            "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 Oct 1, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.