Provider Demographics
NPI:1659490597
Name:QUICK DOC NC, PA
Entity Type:Organization
Organization Name:QUICK DOC NC, PA
Other - Org Name:OLD TOWN IMMEDIATE CARE, P.A.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:FRANKLIN
Authorized Official - Last Name:TRIPP
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:336-993-3146
Mailing Address - Street 1:3734 REYNOLDA RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-2240
Mailing Address - Country:US
Mailing Address - Phone:336-922-1102
Mailing Address - Fax:336-922-5012
Practice Address - Street 1:3734 REYNOLDA RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-2240
Practice Address - Country:US
Practice Address - Phone:336-922-1102
Practice Address - Fax:336-922-5012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208D00000X
NC40655261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC40655OtherMEDICAL BOARD
NC5922000Medicaid
NC01791OtherBLS
NC5922000Medicaid
NC01791OtherBLS