Basic Information
| Provider Information | |||||||||
| NPI: | 1437418142 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MCPC-8, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 896208 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282896208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9108785100 | ||||||||
| FaxNumber: | 9108785140 | ||||||||
| Practice Location | |||||||||
| Address1: | 4565 FAYETTEVILLE RD | ||||||||
| Address2: | |||||||||
| City: | RAEFORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283767998 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9108785100 | ||||||||
| FaxNumber: | 9108785140 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2012 | ||||||||
| LastUpdateDate: | 10/13/2017 | ||||||||
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| AuthorizedOfficialLastName: | DEJACO | ||||||||
| AuthorizedOfficialFirstName: | LYNN | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9107151913 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5920446 | 05 | NC | MEDICAID | 027CG | 01 | NC | BCBS | OTHER |