Basic Information
| Provider Information | |||||||||
| NPI: | 1184882045 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | UNC FAMILY PRACTICE AT CHAPEL HILL | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5221 PARAMOUNT PKWY STE 420 | ||||||||
| Address2: | |||||||||
| City: | MORRISVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275605491 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 101 MANNING DR | ||||||||
| Address2: | |||||||||
| City: | CHAPEL HILL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275144220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9849740210 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2008 | ||||||||
| LastUpdateDate: | 02/19/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SLEDGE | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | W. | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9199664161 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL | ||||||||
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| NPICertificationDate: | 02/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 7907039 | 05 | NC | MEDICAID |