Provider Demographics
NPI:1245561745
Name:GENERAL MEDICAL PRACTICE AND URGENT CARE, PA
Entity Type:Organization
Organization Name:GENERAL MEDICAL PRACTICE AND URGENT CARE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:CHILEATHA
Authorized Official - Middle Name:
Authorized Official - Last Name:WYNN
Authorized Official - Suffix:
Authorized Official - Credentials:MS,PA-C
Authorized Official - Phone:919-383-0003
Mailing Address - Street 1:3505 N ROXBORO ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-2767
Mailing Address - Country:US
Mailing Address - Phone:919-383-0003
Mailing Address - Fax:919-382-0042
Practice Address - Street 1:3505 N ROXBORO ST
Practice Address - Street 2:SUITE C
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-2767
Practice Address - Country:US
Practice Address - Phone:919-383-0003
Practice Address - Fax:919-382-0042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-22
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC010-00919261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCWYPA80321Medicare UPIN