Provider Demographics
NPI:1528045390
Name:FAMILY MEDICAL CARE OF ROWAN PA
Entity Type:Organization
Organization Name:FAMILY MEDICAL CARE OF ROWAN PA
Other - Org Name:NICKERSON FAMILY MEDICAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:LLOYD
Authorized Official - Middle Name:EMERY
Authorized Official - Last Name:NICKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-633-7070
Mailing Address - Street 1:300 N SALISBURY AVE
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:NC
Mailing Address - Zip Code:28159-2514
Mailing Address - Country:US
Mailing Address - Phone:704-633-7070
Mailing Address - Fax:704-633-7627
Practice Address - Street 1:300 N SALISBURY AVE
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:NC
Practice Address - Zip Code:28159-2514
Practice Address - Country:US
Practice Address - Phone:704-633-7070
Practice Address - Fax:704-633-7627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-22
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89014CEOtherMEDICAID
0138ROtherBCBS GROUP ID
202595OtherBLACK LUNG
NC890138RMedicaid
NCCL2573OtherRAILROAD MEDICARE
970029646OtherMEDICARE RAILROAD
NC8962644Medicaid
500013139OtherMEDICARE RAILROAD
62644OtherBCBS PERSONAL ID
NC8962644Medicaid
2591078Medicare ID - Type Unspecified
0138ROtherBCBS GROUP ID
S68763Medicare UPIN
2141141BMedicare ID - Type UnspecifiedID
NC890138RMedicaid
010025945Medicare ID - Type UnspecifiedRAILROAD MEDICARE
=========OtherALL OTHER COMMERCIAL CARR
62644OtherBCBS PERSONAL ID
NC89014CEOtherMEDICAID
202595OtherBLACK LUNG