Basic Information
| Provider Information | |||||||||
| NPI: | 1962737452 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MCPC-2, LLC | ||||||||
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| OtherOrganizationName: | FIRSTHEALTH RICHMOND MEDICAL GROUP INTERNAL MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 896208 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282896208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107151010 | ||||||||
| FaxNumber: | 9107151026 | ||||||||
| Practice Location | |||||||||
| Address1: | 809 S LONG DR STE H | ||||||||
| Address2: | |||||||||
| City: | ROCKINGHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283794317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104174005 | ||||||||
| FaxNumber: | 9104174014 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2009 | ||||||||
| LastUpdateDate: | 09/15/2021 | ||||||||
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| AuthorizedOfficialLastName: | FOSTER | ||||||||
| AuthorizedOfficialFirstName: | MICKEY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9107151443 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | NPB344 | 05 | SC | MEDICAID |