Provider Demographics
NPI:1790823672
Name:INDIAN TRAIL MEDICAL CLINIC, INC.
Entity Type:Organization
Organization Name:INDIAN TRAIL MEDICAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:SC
Authorized Official - Last Name:TSAI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-821-7056
Mailing Address - Street 1:PO BOX 430
Mailing Address - Street 2:
Mailing Address - City:INDIAN TRAIL
Mailing Address - State:NC
Mailing Address - Zip Code:28079-0430
Mailing Address - Country:US
Mailing Address - Phone:704-821-7056
Mailing Address - Fax:704-821-7057
Practice Address - Street 1:301 S. INDIAN TRAIL ROAD
Practice Address - Street 2:
Practice Address - City:INDIAN TRAIL
Practice Address - State:NC
Practice Address - Zip Code:28079
Practice Address - Country:US
Practice Address - Phone:704-821-7056
Practice Address - Fax:704-821-7057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC22284174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8901856Medicaid
NC01856OtherBCBS PROVIDER NUMBER
NCC86836Medicare UPIN
NC0893Medicare ID - Type UnspecifiedPROVIDER NUMBER