Provider Demographics
NPI:1881663227
Name:CHICORA MEDICAL GROUP PA
Entity Type:Organization
Organization Name:CHICORA MEDICAL GROUP PA
Other - Org Name:BRUNSWICK SPECIALITY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BERNARD
Authorized Official - Middle Name:LEROY
Authorized Official - Last Name:LANGSTON
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:910-754-8731
Mailing Address - Street 1:PO BOX 2528
Mailing Address - Street 2:
Mailing Address - City:SHALLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28459
Mailing Address - Country:US
Mailing Address - Phone:910-754-8600
Mailing Address - Fax:910-755-2364
Practice Address - Street 1:20 MEDICAL CAMPUS DR
Practice Address - Street 2:STE 106B
Practice Address - City:SUPPLY
Practice Address - State:NC
Practice Address - Zip Code:28462
Practice Address - Country:US
Practice Address - Phone:910-754-8600
Practice Address - Fax:910-755-2364
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-17
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5900666Medicaid
NC2316664AMedicare PIN