Provider Demographics
NPI:1184749574
Name:FAMILY MEDICAL CENTER
Entity type:Organization
Organization Name:FAMILY MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:RONNIE
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:OUTEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-624-3790
Mailing Address - Street 1:303 WEST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:MARSHVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28103-0648
Mailing Address - Country:US
Mailing Address - Phone:704-624-3790
Mailing Address - Fax:704-624-3578
Practice Address - Street 1:2820 BELK MILL RD
Practice Address - Street 2:
Practice Address - City:WINGATE
Practice Address - State:NC
Practice Address - Zip Code:28174-8764
Practice Address - Country:US
Practice Address - Phone:704-624-3790
Practice Address - Fax:704-624-3578
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9900973261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891293GMedicaid
NC891293GMedicaid
NCH51565Medicare UPIN