Basic Information
| Provider Information | |||||||||
| NPI: | 1427260108 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FIRST CARE MEDICAL CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 404 S SUTHERLAND AVE | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281125060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042919267 | ||||||||
| FaxNumber: | 7042250428 | ||||||||
| Practice Location | |||||||||
| Address1: | 7884 IDLEWILD ROAD | ||||||||
| Address2: | |||||||||
| City: | INDIANTRAIL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042919267 | ||||||||
| FaxNumber: | 7042917413 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2007 | ||||||||
| LastUpdateDate: | 04/14/2010 | ||||||||
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| AuthorizedOfficialLastName: | OKWARA | ||||||||
| AuthorizedOfficialFirstName: | BENEDICT | ||||||||
| AuthorizedOfficialMiddleName: | O | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7042919267 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | E85143 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 2080A0000X | E85143 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine | 207R00000X | E85143 | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2326436 | 01 | NC | MEDICARE GROUP # | OTHER |