Provider Demographics
NPI:1275595795
Name:FIRST FOUNDATION CLINIC OF THE CAROLINAS CHARLOTTE, PC
Entity Type:Organization
Organization Name:FIRST FOUNDATION CLINIC OF THE CAROLINAS CHARLOTTE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DONATUS
Authorized Official - Middle Name:O
Authorized Official - Last Name:OGU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-866-4607
Mailing Address - Street 1:PO BOX 471279
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28247-1279
Mailing Address - Country:US
Mailing Address - Phone:704-567-0465
Mailing Address - Fax:704-567-2940
Practice Address - Street 1:4938 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-5871
Practice Address - Country:US
Practice Address - Phone:704-567-0465
Practice Address - Fax:704-567-2940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-03
Last Update Date:2009-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89016H3Medicaid
NC89016H3Medicaid