Provider Demographics
NPI:1851630172
Name:MEDICAL PLAZA FAMILY & GERIATRIC PHYSICIANS, PA
Entity Type:Organization
Organization Name:MEDICAL PLAZA FAMILY & GERIATRIC PHYSICIANS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-944-0975
Mailing Address - Street 1:8401 MEDICAL PLAZA DR
Mailing Address - Street 2:SUITE 365
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-8797
Mailing Address - Country:US
Mailing Address - Phone:704-944-0975
Mailing Address - Fax:704-943-0699
Practice Address - Street 1:8401 MEDICAL PLAZA DR
Practice Address - Street 2:SUITE 365
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-8797
Practice Address - Country:US
Practice Address - Phone:704-944-0975
Practice Address - Fax:704-943-0699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-06
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC189833207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5922886Medicaid
NC5922886Medicaid