Provider Demographics
NPI:1780629154
Name:CLINTON MEDICAL CLINIC, INC.
Entity Type:Organization
Organization Name:CLINTON MEDICAL CLINIC, INC.
Other - Org Name:CLINTON MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:Q
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:910-590-0619
Mailing Address - Street 1:403 FAIRVIEW ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NC
Mailing Address - Zip Code:28328-2399
Mailing Address - Country:US
Mailing Address - Phone:910-592-6011
Mailing Address - Fax:910-592-0811
Practice Address - Street 1:403 FAIRVIEW ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NC
Practice Address - Zip Code:28328-2399
Practice Address - Country:US
Practice Address - Phone:910-592-6011
Practice Address - Fax:910-592-0811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207Q00000X, 208000000X, 363A00000X, 363L00000X
208D00000X, 363LF0000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8382628NOtherAETNA
NC8901340Medicaid
NC01340OtherNCBLUE CROSS BLUE SHIELD
NC00321919Medicaid
NC=========AOtherCIGNA