Provider Demographics
NPI:1669664264
Name:MOUNTAIN ISLAND FAMILY MEDICINE, PC
Entity Type:Organization
Organization Name:MOUNTAIN ISLAND FAMILY MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CLAYTON
Authorized Official - Middle Name:R
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-399-1415
Mailing Address - Street 1:10226 COULOAK DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28216-7675
Mailing Address - Country:US
Mailing Address - Phone:704-399-1415
Mailing Address - Fax:704-399-1415
Practice Address - Street 1:10226 COULOAK DR
Practice Address - Street 2:SUITE 110
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28216-7675
Practice Address - Country:US
Practice Address - Phone:704-399-1415
Practice Address - Fax:704-399-1415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-16
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC125435261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2347033Medicare PIN