Provider Demographics
NPI:1902813223
Name:VERNON, MICHAEL STEPHEN (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:STEPHEN
Last Name:VERNON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60063
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0063
Mailing Address - Country:US
Mailing Address - Phone:704-302-8100
Mailing Address - Fax:704-302-8101
Practice Address - Street 1:15110 JOHN J DELANEY DR
Practice Address - Street 2:SUITE 200
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-3545
Practice Address - Country:US
Practice Address - Phone:704-302-8100
Practice Address - Fax:704-302-8101
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC28362207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8985031Medicaid
NCC02528Medicare UPIN
NC8985031Medicaid
SCAA37609246Medicare PIN
NC211176EMedicare PIN
NC211176AMedicare UPIN
NC211176CMedicare ID - Type UnspecifiedMCR