Basic Information
| Provider Information | |||||||||
| NPI: | 1649373788 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAYETTEVILLE GERIATRIC & INTERNAL MEDICINE CLINIC PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1689 | ||||||||
| Address2: | |||||||||
| City: | ETOWAH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287291689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8288915524 | ||||||||
| FaxNumber: | 8288914069 | ||||||||
| Practice Location | |||||||||
| Address1: | 3616 CAPE CENTER DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9108686730 | ||||||||
| FaxNumber: | 9108299649 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2006 | ||||||||
| LastUpdateDate: | 06/11/2014 | ||||||||
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| AuthorizedOfficialLastName: | RAHMAN | ||||||||
| AuthorizedOfficialFirstName: | MOHAMMED | ||||||||
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| AuthorizedOfficialTitleorPosition: | DOCTOR | ||||||||
| AuthorizedOfficialTelephone: | 9108686730 | ||||||||
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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 | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 891163K | 05 | NC | MEDICAID | 1163K | 01 | BLUE CROSS BLUE SHIELD | OTHER |