Provider Demographics
NPI:1114351095
Name:MCPC-16, LLC
Entity Type:Organization
Organization Name:MCPC-16, LLC
Other - Org Name:FIRSTHEALTH PRIMARY CARE AND CARDIOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:S
Authorized Official - Last Name:DEJACO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-715-1913
Mailing Address - Street 1:6322 FAYETTEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:RAEFORD
Mailing Address - State:NC
Mailing Address - Zip Code:28376-7979
Mailing Address - Country:US
Mailing Address - Phone:910-878-6700
Mailing Address - Fax:910-878-6705
Practice Address - Street 1:6322 FAYETTEVILLE RD
Practice Address - Street 2:
Practice Address - City:RAEFORD
Practice Address - State:NC
Practice Address - Zip Code:28376-7979
Practice Address - Country:US
Practice Address - Phone:910-878-6700
Practice Address - Fax:910-878-6705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-27
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1114351095Medicaid
NC1114351095Medicaid