Basic Information
| Provider Information | |||||||||
| NPI: | 1053074369 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MCPC-22, LLC | ||||||||
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| OtherOrganizationName: | FIRSTHEALTH - SANDHILLS NEUROLOGISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 896208 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282896208 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 295 OLMSTED BLVD BLDG STE 12 | ||||||||
| Address2: | |||||||||
| City: | PINEHURST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283748734 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103757344 | ||||||||
| FaxNumber: | 9102350546 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2021 | ||||||||
| LastUpdateDate: | 11/03/2021 | ||||||||
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| AuthorizedOfficialLastName: | FOSTER | ||||||||
| AuthorizedOfficialFirstName: | MICKEY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9107151442 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.