Provider Demographics
NPI:1235303264
Name:CALVARY MEDICAL CLINIC PA
Entity Type:Organization
Organization Name:CALVARY MEDICAL CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAGDALENE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARFO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-979-8210
Mailing Address - Street 1:PO BOX 79029
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28271-7046
Mailing Address - Country:US
Mailing Address - Phone:704-979-8210
Mailing Address - Fax:877-492-8881
Practice Address - Street 1:537 W SUGAR CREEK RD
Practice Address - Street 2:SUITE 201
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28213-6102
Practice Address - Country:US
Practice Address - Phone:704-979-8210
Practice Address - Fax:877-492-8881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2001-01471207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
H52959Medicare UPIN