Basic Information
| Provider Information | |||||||||
| NPI: | 1740499714 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAROLINA FAMILY MEDICINE & URGENT CARE PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1503 E BROAD ST | ||||||||
| Address2: | |||||||||
| City: | STATESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286254301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048719731 | ||||||||
| FaxNumber: | 7048711105 | ||||||||
| Practice Location | |||||||||
| Address1: | 1503 E BROAD ST | ||||||||
| Address2: | |||||||||
| City: | STATESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286254301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048719731 | ||||||||
| FaxNumber: | 7048711105 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2007 | ||||||||
| LastUpdateDate: | 06/26/2012 | ||||||||
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| AuthorizedOfficialLastName: | BROWN | ||||||||
| AuthorizedOfficialFirstName: | CODEY | ||||||||
| AuthorizedOfficialMiddleName: | JEAN | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER/DELEGATED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 7048719731 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 200001772371 | NC | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 89014W8 | 05 | NC | MEDICAID | 014W8 | 01 | NC | BCBSNC | OTHER |