Provider Demographics
NPI:1790812840
Name:GERIDOC LLC
Entity Type:Organization
Organization Name:GERIDOC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:SHEDERICK
Authorized Official - Last Name:FORD
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:704-564-9030
Mailing Address - Street 1:4431 MONTIBELLO DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-7420
Mailing Address - Country:US
Mailing Address - Phone:704-564-9030
Mailing Address - Fax:
Practice Address - Street 1:4431 MONTIBELLO DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-7420
Practice Address - Country:US
Practice Address - Phone:704-564-9030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC930069207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC32996OtherBCBS
NC5909094Medicaid
NCDG7956Medicare PIN
NC32996OtherBCBS