Provider Demographics
NPI:1568916617
Name:FAMHEALTH PRIMARY CARE , PA
Entity Type:Organization
Organization Name:FAMHEALTH PRIMARY CARE , PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:ENID
Authorized Official - Middle Name:MATOS
Authorized Official - Last Name:TALLMER
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:919-697-5388
Mailing Address - Street 1:5720 CREEDMOOR RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-2256
Mailing Address - Country:US
Mailing Address - Phone:919-782-0430
Mailing Address - Fax:
Practice Address - Street 1:5720 CREEDMOOR RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-2256
Practice Address - Country:US
Practice Address - Phone:919-782-0430
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-06
Last Update Date:2016-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC2016204005421261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care