Provider Demographics
NPI:1407271109
Name:CENTRAL CAROLINA MEDICAL CLINIC, PA
Entity Type:Organization
Organization Name:CENTRAL CAROLINA MEDICAL CLINIC, PA
Other - Org Name:CENTRAL CAROLINA MEDICAL CLINIC, PA - PAW CREEK CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:TUONG
Authorized Official - Middle Name:
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-532-8884
Mailing Address - Street 1:6404 ALBEMARLE ROAD
Mailing Address - Street 2:SUITE J & K
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28214
Mailing Address - Country:US
Mailing Address - Phone:704-532-8884
Mailing Address - Fax:704-532-8789
Practice Address - Street 1:515 LITTLE ROCK ROAD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28214
Practice Address - Country:US
Practice Address - Phone:704-532-8884
Practice Address - Fax:704-532-8789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-04
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2008-00070207Q00000X
NC2000-00566207R00000X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty