Provider Demographics
NPI:1427006865
Name:MULLIS, GARRICK BRENT (MD)
Entity Type:Individual
Prefix:
First Name:GARRICK
Middle Name:BRENT
Last Name:MULLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1028 LEE ANN DR NE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-2911
Mailing Address - Country:US
Mailing Address - Phone:704-782-1892
Mailing Address - Fax:
Practice Address - Street 1:1028 LEE ANN DR NE
Practice Address - Street 2:SUITE 200
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2911
Practice Address - Country:US
Practice Address - Phone:704-782-1892
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200400719207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC232279Medicaid
NC136YHOtherBCBS
NC89136YHMedicaid
NC136YHOtherBCBS
SC232279Medicaid
NC2028170Medicare PIN