Provider Demographics
NPI:1457638116
Name:CHARLOTTE MEDICAL CLINIC INC
Entity Type:Organization
Organization Name:CHARLOTTE MEDICAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:FORD
Authorized Official - Last Name:LAYMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-631-0002
Mailing Address - Street 1:PO BOX 601643
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1643
Mailing Address - Country:US
Mailing Address - Phone:704-667-6750
Mailing Address - Fax:704-667-6751
Practice Address - Street 1:2700 PROVIDENCE RD S
Practice Address - Street 2:SUITE 320
Practice Address - City:WAXHAW
Practice Address - State:NC
Practice Address - Zip Code:28173-6313
Practice Address - Country:US
Practice Address - Phone:704-667-6750
Practice Address - Fax:704-667-6751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-09
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
NC207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5919381Medicaid
SCNPB549Medicaid
NC2308414Medicare PIN