Provider Demographics
NPI:1225133135
Name:WADESBORO FAMILY MEDICINE PA
Entity Type:Organization
Organization Name:WADESBORO FAMILY MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:BRACEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-694-3599
Mailing Address - Street 1:212 S RUTHERFORD ST
Mailing Address - Street 2:
Mailing Address - City:WADESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28170
Mailing Address - Country:US
Mailing Address - Phone:704-694-3599
Mailing Address - Fax:704-695-1759
Practice Address - Street 1:212 S RUTHERFORD ST
Practice Address - Street 2:WADESBORO FAMILY MEDICINE PA
Practice Address - City:WADESBORO
Practice Address - State:NC
Practice Address - Zip Code:28170
Practice Address - Country:US
Practice Address - Phone:704-694-3599
Practice Address - Fax:704-695-1759
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9600327207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891003TMedicaid
G28267Medicare UPIN
NC2224998BMedicare ID - Type Unspecified