Provider Demographics
NPI:1942255708
Name:STANLY FAMILY CARE CLINIC PA
Entity Type:Organization
Organization Name:STANLY FAMILY CARE CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:MERRIMAN
Authorized Official - Last Name:JOHNSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-983-3121
Mailing Address - Street 1:1007 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:ALBEMARLE
Mailing Address - State:NC
Mailing Address - Zip Code:28001-3551
Mailing Address - Country:US
Mailing Address - Phone:704-983-3121
Mailing Address - Fax:704-983-4659
Practice Address - Street 1:1007 N 6TH ST
Practice Address - Street 2:
Practice Address - City:ALBEMARLE
Practice Address - State:NC
Practice Address - Zip Code:28001-3551
Practice Address - Country:US
Practice Address - Phone:704-983-3121
Practice Address - Fax:704-983-4659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC24425207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC46027OtherBCBS IND.
NC890243CMedicaid
NC0243COtherBCBS GROUP
NC080077493OtherRAILROAD MEDICARE
0372050001Medicare NSC
NC1171Medicare ID - Type UnspecifiedMEDICARE GROUP
NC080077493OtherRAILROAD MEDICARE
NC202350CMedicare ID - Type UnspecifiedMEDICARE INDIVIDUAL