Provider Demographics
NPI:1477512812
Name:CAROLINA ADULT MEDICINE, PA
Entity Type:Organization
Organization Name:CAROLINA ADULT MEDICINE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:GRUCHACZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:252-438-7777
Mailing Address - Street 1:568 RUIN CREEK RD
Mailing Address - Street 2:SUITE 002
Mailing Address - City:HENDERSON
Mailing Address - State:NC
Mailing Address - Zip Code:27536-2880
Mailing Address - Country:US
Mailing Address - Phone:252-438-7777
Mailing Address - Fax:252-438-7190
Practice Address - Street 1:568 RUIN CREEK RD
Practice Address - Street 2:SUITE 002
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27536-2880
Practice Address - Country:US
Practice Address - Phone:252-438-7777
Practice Address - Fax:252-438-7190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9700258207R00000X
NC9701734207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC016G2OtherBCBS GROUP NUMBER
NC89016G2Medicaid
NC2330552Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER