Provider Demographics
NPI:1104010156
Name:CUPID FAMILY PRACTICE PA
Entity Type:Organization
Organization Name:CUPID FAMILY PRACTICE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:JO-ANN
Authorized Official - Last Name:CUPID
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-971-4445
Mailing Address - Street 1:2325 W. ARBORS DR.
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-2559
Mailing Address - Country:US
Mailing Address - Phone:704-971-4445
Mailing Address - Fax:704-971-4450
Practice Address - Street 1:2325 W. ARBORS DR.
Practice Address - Street 2:SUITE 102
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-2559
Practice Address - Country:US
Practice Address - Phone:704-971-4445
Practice Address - Fax:704-971-4450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-04
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200301427174400000X, 207Q00000X
SC21652207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC216527Medicaid
SC216527Medicaid