Provider Demographics
NPI:1043761513
Name:APPALACHIAN DISTRICT HEALTH DEPARTMENT
Entity type:Organization
Organization Name:APPALACHIAN DISTRICT HEALTH DEPARTMENT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALER/BILLING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-246-9449
Mailing Address - Street 1:PO BOX 208
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:NC
Mailing Address - Zip Code:28640-0208
Mailing Address - Country:US
Mailing Address - Phone:336-246-9449
Mailing Address - Fax:336-982-3555
Practice Address - Street 1:225 COURT ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:NC
Practice Address - Zip Code:28640-9696
Practice Address - Country:US
Practice Address - Phone:336-246-9449
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:APPALACHIAN DISTRICT HEALTH DEPARTMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-20
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103561223G0001X
261QP0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2344747AOtherMEDICARE PTAN
NC3404305Medicaid