Provider Demographics
NPI:1326000845
Name:METROLINA INTERNAL MEDICINE PA
Entity Type:Organization
Organization Name:METROLINA INTERNAL MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CLARENCE
Authorized Official - Middle Name:O'NEIL
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-372-9393
Mailing Address - Street 1:2300 RANDOLPH RD STE A
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28207-1586
Mailing Address - Country:US
Mailing Address - Phone:704-372-9393
Mailing Address - Fax:704-372-0135
Practice Address - Street 1:2300 RANDOLPH RD STE A
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1586
Practice Address - Country:US
Practice Address - Phone:704-372-9393
Practice Address - Fax:704-372-0135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-03
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC83588207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC790278JMedicaid
NC2325822Medicare ID - Type Unspecified