Provider Demographics
NPI:1235515446
Name:CLEVELAND FAMILY HEALTH CLINIC, PLLC
Entity Type:Organization
Organization Name:CLEVELAND FAMILY HEALTH CLINIC, PLLC
Other - Org Name:MARIAN J. BULLARD PLLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:BULLARD
Authorized Official - Suffix:
Authorized Official - Credentials:PA C
Authorized Official - Phone:919-662-7600
Mailing Address - Street 1:22 SHIPWASH DR
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-6861
Mailing Address - Country:US
Mailing Address - Phone:919-662-7600
Mailing Address - Fax:
Practice Address - Street 1:22 SHIPWASH DRIVE
Practice Address - Street 2:
Practice Address - City:GARNER
Practice Address - State:NC
Practice Address - Zip Code:27529
Practice Address - Country:US
Practice Address - Phone:919-662-7600
Practice Address - Fax:919-662-7675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-11
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2011-00283207Q00000X
NC0010-01664363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1538304837Medicaid
NC1538304837Medicaid