Provider Demographics
NPI:1467481762
Name:MT OLIVE FAMILY MEDICINE CENTER INC
Entity Type:Organization
Organization Name:MT OLIVE FAMILY MEDICINE CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:DUNN
Authorized Official - Last Name:DILDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-581-4960
Mailing Address - Street 1:201 N BREAZEALE AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT OLIVE
Mailing Address - State:NC
Mailing Address - Zip Code:28365-1603
Mailing Address - Country:US
Mailing Address - Phone:919-658-4954
Mailing Address - Fax:919-658-5754
Practice Address - Street 1:201 N BREAZEALE AVE
Practice Address - Street 2:
Practice Address - City:MOUNT OLIVE
Practice Address - State:NC
Practice Address - Zip Code:28365-1603
Practice Address - Country:US
Practice Address - Phone:919-658-4954
Practice Address - Fax:919-658-5754
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC230260AMedicare ID - Type UnspecifiedFAMILY PRACTICE