Provider Demographics
NPI:1821059650
Name:POLYCLINIC MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:POLYCLINIC MEDICAL CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOSI
Authorized Official - Middle Name:BRAZ
Authorized Official - Last Name:GARUBA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-844-8971
Mailing Address - Street 1:9705 NORTHEAST PKWY STE 400
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-9704
Mailing Address - Country:US
Mailing Address - Phone:704-844-8971
Mailing Address - Fax:704-844-8972
Practice Address - Street 1:9705 NORTHEAST PKWY STE 400
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-9704
Practice Address - Country:US
Practice Address - Phone:704-844-8971
Practice Address - Fax:704-844-8972
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-31
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2000-01378207RC0200X
NC25646208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5903156Medicaid
NC5903156Medicaid