Provider Demographics
NPI:1588859953
Name:ST MARY'S MEDICAL CLINIC,PC.
Entity Type:Organization
Organization Name:ST MARY'S MEDICAL CLINIC,PC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AWAWU
Authorized Official - Middle Name:E
Authorized Official - Last Name:IGBINADOLOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-219-2147
Mailing Address - Street 1:701 E ROOSEVELT BLVD, BLDG 800A
Mailing Address - Street 2:P.O.BOX 528
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28111-0528
Mailing Address - Country:US
Mailing Address - Phone:704-225-0211
Mailing Address - Fax:704-225-0221
Practice Address - Street 1:701 E ROOSEVELT BLVD
Practice Address - Street 2:BLDG 800A
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112
Practice Address - Country:US
Practice Address - Phone:704-225-0211
Practice Address - Fax:704-225-0221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-10
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200001486832261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care