Provider Demographics
NPI:1215205539
Name:AVE MARIA FAMILY PRACTICE, PLLC
Entity Type:Organization
Organization Name:AVE MARIA FAMILY PRACTICE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:EJINKONYE
Authorized Official - Last Name:AGBAFE-MOSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-799-5452
Mailing Address - Street 1:PO BOX 16663
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28408-6663
Mailing Address - Country:US
Mailing Address - Phone:910-799-5452
Mailing Address - Fax:910-799-5479
Practice Address - Street 1:1230 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401
Practice Address - Country:US
Practice Address - Phone:910-799-5452
Practice Address - Fax:910-799-5479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-01
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2009-01999207Q00000X, 261QP2300X
NC179288261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5915683Medicaid