Provider Demographics
NPI:1619908233
Name:ROXBORO FAMILY MEDICINE & IMMEDIATE
Entity Type:Organization
Organization Name:ROXBORO FAMILY MEDICINE & IMMEDIATE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:P
Authorized Official - Last Name:SHOCK
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:336-598-5480
Mailing Address - Street 1:PO BOX 61474
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27715-1474
Mailing Address - Country:US
Mailing Address - Phone:919-544-6318
Mailing Address - Fax:919-544-6336
Practice Address - Street 1:228 S MADISON BLVD
Practice Address - Street 2:
Practice Address - City:ROXBORO
Practice Address - State:NC
Practice Address - Zip Code:27573-5428
Practice Address - Country:US
Practice Address - Phone:336-598-5480
Practice Address - Fax:336-598-5482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2009-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC014M1OtherBCBS-NC GROUP NO
NC5903189Medicaid
NC2331881Medicare ID - Type UnspecifiedMEDICARE GROUP NO
NC6132390001Medicare NSC