1306175476 NPI number — MECKLENBURG MEDICAL GROUP

Table of content: (NPI 1306175476)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306175476 NPI number — MECKLENBURG MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MECKLENBURG MEDICAL GROUP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306175476
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/12/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 601643
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28260-1643
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-302-9700
Provider Business Mailing Address Fax Number:
704-302-9701

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1550 FAULK ST
Provider Second Line Business Practice Location Address:
SUITE 1500
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28112-5086
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-302-9700
Provider Business Practice Location Address Fax Number:
704-302-9701
Provider Enumeration Date:
12/18/2009

Additional Information

Authorized Official

Authorized Official Last Name:
LAYMON
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
FORD
Authorized Official Title or Position:
SENIOR VICE PRESIDENT
Authorized Official Telephone Number:
704-631-0002

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: NPB352 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5914037 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7705296 . This is a "MEDICAID DME" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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