Provider Demographics
NPI:1518343573
Name:THE FAMILY DOC BACK TO BASICS MEDICAL PRACTICE, PLLC
Entity Type:Organization
Organization Name:THE FAMILY DOC BACK TO BASICS MEDICAL PRACTICE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:PATTERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-895-6339
Mailing Address - Street 1:1503 ELM STREET, SUITE C
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27330
Mailing Address - Country:US
Mailing Address - Phone:919-895-6339
Mailing Address - Fax:919-590-1981
Practice Address - Street 1:1503 ELM STREET, SUITE C
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330
Practice Address - Country:US
Practice Address - Phone:919-895-6339
Practice Address - Fax:919-590-1981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-31
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC23907207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty