Basic Information
| Provider Information | |||||||||
| NPI: | 1972719698 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARRBORO FAMILY MEDICINE CENTER, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 610 JONES FERRY RD | ||||||||
| Address2: | STE 102 | ||||||||
| City: | CARRBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275106113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199291747 | ||||||||
| FaxNumber: | 9199335168 | ||||||||
| Practice Location | |||||||||
| Address1: | 610 JONES FERRY RD | ||||||||
| Address2: | STE 102 | ||||||||
| City: | CARRBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275106113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199291747 | ||||||||
| FaxNumber: | 9199335168 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2007 | ||||||||
| LastUpdateDate: | 11/02/2021 | ||||||||
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| AuthorizedOfficialLastName: | BULLOCK | ||||||||
| AuthorizedOfficialFirstName: | RUTH | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATIVE ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 9199291747 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1972719698 | 05 | NC | MEDICAID |