Provider Demographics
NPI:1275673097
Name:SOUTHERN CLINICS AND URGENT CARE, PA
Entity Type:Organization
Organization Name:SOUTHERN CLINICS AND URGENT CARE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:THORNTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-865-2755
Mailing Address - Street 1:PO BOX 550490
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28055-0490
Mailing Address - Country:US
Mailing Address - Phone:704-865-2755
Mailing Address - Fax:704-865-5013
Practice Address - Street 1:812 W INNES ST
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-4152
Practice Address - Country:US
Practice Address - Phone:704-637-5544
Practice Address - Fax:704-637-1989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102847261QP2300X
NC009600205261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89012X5Medicaid
NC89012X5Medicaid
F41744Medicare UPIN
NC272670DMedicare ID - Type UnspecifiedPA MEDICARE #
S95673Medicare UPIN
NC89012X5Medicaid