Provider Demographics
| NPI: | 1477879260 |
|---|---|
| Name: | MECKLENBURG MEDICAL GROUP |
| Entity Type: | Organization |
| Organization Name: | MECKLENBURG MEDICAL GROUP |
| 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: | 704-302-8350 |
| Mailing Address - Fax: | 704-302-8351 |
| Practice Address - Street 1: | 4525 CAMERON VALLEY PKWY |
| Practice Address - Street 2: | SUITE 2100 |
| Practice Address - City: | CHARLOTTE |
| Practice Address - State: | NC |
| Practice Address - Zip Code: | 28211-4369 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 704-302-8350 |
| Practice Address - Fax: | 704-302-8351 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2010-04-19 |
| Last Update Date: | 2016-08-15 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 332B00000X | Suppliers | Durable Medical Equipment & Medical Supplies | Group - Multi-Specialty | |
| No | 207N00000X | Allopathic & Osteopathic Physicians | Dermatology | Group - Multi-Specialty | |
| No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
| No | 207RB0002X | Allopathic & Osteopathic Physicians | Internal Medicine | Obesity Medicine | Group - Multi-Specialty |
| No | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | Group - Multi-Specialty |
| No | 207RE0101X | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | Group - Multi-Specialty |
| No | 207RG0100X | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | Group - Multi-Specialty |
| No | 207RG0300X | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | Group - Multi-Specialty |
| No | 207RH0003X | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | Group - Multi-Specialty |
| No | 207RI0200X | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | Group - Multi-Specialty |
| No | 207RP1001X | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | Group - Multi-Specialty |
| No | 207RR0500X | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | Group - Multi-Specialty |
| No | 207RS0012X | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine | Group - Multi-Specialty |
| No | 207RX0202X | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| NC | 89013C0 | Medicaid | |
| SC | E08621 | Medicaid | |
| NC | 1477879260 | Medicaid | |
| NC | 89013C0 | Medicaid |
