Provider Demographics
NPI:1922158203
Name:CMG- FAMILY MEDICINE OF CLEVELAND COUNTY LLC
Entity Type:Organization
Organization Name:CMG- FAMILY MEDICINE OF CLEVELAND COUNTY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT,CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:VALINDA
Authorized Official - Middle Name:L
Authorized Official - Last Name:RUTLEDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-834-2133
Mailing Address - Street 1:2240 REMOUNT RD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-4725
Mailing Address - Country:US
Mailing Address - Phone:704-671-5311
Mailing Address - Fax:704-671-5308
Practice Address - Street 1:807 SCHENCK ST # 3
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-3933
Practice Address - Country:US
Practice Address - Phone:704-480-0222
Practice Address - Fax:704-480-6007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2010-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5905777Medicaid
NC5905777Medicaid