Basic Information
| Provider Information | |||||||||
| NPI: | 1851630172 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDICAL PLAZA FAMILY & GERIATRIC PHYSICIANS, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8401 MEDICAL PLAZA DR | ||||||||
| Address2: | SUITE 365 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282628797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049440975 | ||||||||
| FaxNumber: | 7049430699 | ||||||||
| Practice Location | |||||||||
| Address1: | 8401 MEDICAL PLAZA DR | ||||||||
| Address2: | SUITE 365 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282628797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049440975 | ||||||||
| FaxNumber: | 7049430699 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2013 | ||||||||
| LastUpdateDate: | 02/25/2014 | ||||||||
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| AuthorizedOfficialLastName: | LONG | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7049440975 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QG0300X | 189833 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5922886 | 05 | NC | MEDICAID |