Provider Demographics
NPI:1578844908
Name:CONCORD MEDICAL CLINIC, INC.
Entity Type:Organization
Organization Name:CONCORD MEDICAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:CLAUDIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:704-782-6868
Mailing Address - Street 1:1000 COPPERFIELD BLVD NE
Mailing Address - Street 2:SUITE 124
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-2453
Mailing Address - Country:US
Mailing Address - Phone:704-782-6868
Mailing Address - Fax:704-782-7585
Practice Address - Street 1:1000 COPPERFIELD BLVD NE
Practice Address - Street 2:SUITE 124
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2453
Practice Address - Country:US
Practice Address - Phone:704-782-6868
Practice Address - Fax:704-782-7585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-30
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001001312363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty