Provider Demographics
NPI:1417310491
Name:MURRAY FORK CLINIC, PC
Entity Type:Organization
Organization Name:MURRAY FORK CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NERVA
Authorized Official - Middle Name:
Authorized Official - Last Name:AUGUSTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-764-4750
Mailing Address - Street 1:6020 MORGANTON ROAD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-1352
Mailing Address - Country:US
Mailing Address - Phone:910-764-4750
Mailing Address - Fax:910-764-4752
Practice Address - Street 1:6020 MORGANTON ROAD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28314-1352
Practice Address - Country:US
Practice Address - Phone:910-764-4750
Practice Address - Fax:910-764-4752
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MURRAY FORK CLINIC, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-03-29
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherEIN