Provider Demographics
NPI:1366658833
Name:CLAYTON INTERNAL MEDICINE PC
Entity Type:Organization
Organization Name:CLAYTON INTERNAL MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MAZEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KHUSAYEM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-550-6336
Mailing Address - Street 1:PO BOX 997
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NC
Mailing Address - Zip Code:27528-0997
Mailing Address - Country:US
Mailing Address - Phone:919-550-6336
Mailing Address - Fax:919-550-0180
Practice Address - Street 1:301 AMOS ST
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NC
Practice Address - Zip Code:27520-2644
Practice Address - Country:US
Practice Address - Phone:919-550-6336
Practice Address - Fax:919-550-0180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9900898261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89126XVMedicaid
NC2280894Medicare ID - Type Unspecified
NC89126XVMedicaid