Provider Demographics
NPI:1295993327
Name:PINEHURST MEDICAL CLINIC INC
Entity type:Organization
Organization Name:PINEHURST MEDICAL CLINIC INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CYRUS
Authorized Official - Middle Name:J
Authorized Official - Last Name:FAIRCLOTH
Authorized Official - Suffix:II
Authorized Official - Credentials:
Authorized Official - Phone:910-295-5511
Mailing Address - Street 1:705B LAUCHWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:LAURINBURG
Mailing Address - State:NC
Mailing Address - Zip Code:28352-5544
Mailing Address - Country:US
Mailing Address - Phone:910-266-0111
Mailing Address - Fax:910-277-0055
Practice Address - Street 1:705B LAUCHWOOD DRIVE
Practice Address - Street 2:
Practice Address - City:LAURINBURG
Practice Address - State:NC
Practice Address - Zip Code:28352-5544
Practice Address - Country:US
Practice Address - Phone:910-266-0111
Practice Address - Fax:910-277-0055
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PINEHURST MEDICAL CLINIC, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-27
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC020R0OtherBC/BS NC GROUP PROVIDER#
NC5950379Medicaid
SCNPB301OtherSC MEDICAID GROUP PROVIDER#
CC6114OtherPALMETTO GBA GROUP PROVIDER#
NC020R0OtherBC/BS NC GROUP PROVIDER#