Basic Information
| Provider Information | |||||||||
| NPI: | 1275673097 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN CLINICS AND URGENT CARE, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 550490 | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280550490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048652755 | ||||||||
| FaxNumber: | 7048655013 | ||||||||
| Practice Location | |||||||||
| Address1: | 812 W INNES ST | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281444152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046375544 | ||||||||
| FaxNumber: | 7046371989 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2007 | ||||||||
| LastUpdateDate: | 02/28/2012 | ||||||||
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| AuthorizedOfficialLastName: | THORNTON | ||||||||
| AuthorizedOfficialFirstName: | TARA | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7048652755 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 009600205 | NC | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 261QP2300X | 102847 | NC | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 89012X5 | 05 | NC | MEDICAID |