Provider Demographics
NPI:1134108905
Name:SOUTHERN CLINICS AND URGENT CARE PA
Entity Type:Organization
Organization Name:SOUTHERN CLINICS AND URGENT CARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AUGUSTINE
Authorized Official - Middle Name:R
Authorized Official - Last Name:EZE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-865-2755
Mailing Address - Street 1:PO BOX 550490
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28055-0490
Mailing Address - Country:US
Mailing Address - Phone:704-865-2755
Mailing Address - Fax:704-865-5013
Practice Address - Street 1:502 W KING ST
Practice Address - Street 2:LL 20
Practice Address - City:KINGS MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:28086-3362
Practice Address - Country:US
Practice Address - Phone:704-865-2755
Practice Address - Fax:704-865-5013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2349480Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER