Provider Demographics
NPI:1073518536
Name:FAYETTEVILLE FAMILY MEDICAL CARE, PA
Entity Type:Organization
Organization Name:FAYETTEVILLE FAMILY MEDICAL CARE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:M
Authorized Official - Last Name:KUGLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-323-1718
Mailing Address - Street 1:1307 AVON ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-4423
Mailing Address - Country:US
Mailing Address - Phone:910-323-1718
Mailing Address - Fax:910-323-5701
Practice Address - Street 1:1307 AVON ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-4423
Practice Address - Country:US
Practice Address - Phone:910-323-1718
Practice Address - Fax:910-323-5701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-20
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8901559Medicaid
3442124OtherNCPDP PROVIDER IDENTIFICATION NUMBER
01559OtherBCBS
NC8901559Medicaid