Basic Information
| Provider Information | |||||||||
| NPI: | 1053636472 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHARLOTTE MEDICAL CLINIC INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 601643 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282601643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048639500 | ||||||||
| FaxNumber: | 7043555188 | ||||||||
| Practice Location | |||||||||
| Address1: | 10545 BLAIR ROAD | ||||||||
| Address2: | SUITE 2100 | ||||||||
| City: | MINT HILL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282272804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048639500 | ||||||||
| FaxNumber: | 7043555188 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2010 | ||||||||
| LastUpdateDate: | 08/10/2016 | ||||||||
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| AuthorizedOfficialLastName: | LAYMON | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | FORD | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7046310002 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | 207RA0201X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Allergy & Immunology | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RE0101X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207RG0100X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RP1001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RS0010X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Sports Medicine | 208100000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 332B00000X | NC | N | Suppliers | Durable Medical Equipment & Medical Supplies | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5908921 | 05 | NC | MEDICAID | E04411 | 05 | SC | MEDICAID | 7705275 | 01 | NC | NC MEDICAID DME | OTHER |