Basic Information
| Provider Information | |||||||||
| NPI: | 1720048929 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ERVIN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 896239 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282896239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8039367476 | ||||||||
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| Practice Location | |||||||||
| Address1: | 930 3RD ST | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274056967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368903200 | ||||||||
| FaxNumber: | 3368903290 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2006 | ||||||||
| LastUpdateDate: | 08/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 16917 | SC | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 9500893 | NC | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 169178 | 05 | SC | MEDICAID |