Provider Demographics
NPI:1396935193
Name:COMMUNITY MEDICAL, P.A.
Entity type:Organization
Organization Name:COMMUNITY MEDICAL, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:BRANDI
Authorized Official - Middle Name:SELINA
Authorized Official - Last Name:QUEEN
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:704-292-0708
Mailing Address - Street 1:520 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARSHVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28103-1197
Mailing Address - Country:US
Mailing Address - Phone:704-624-3388
Mailing Address - Fax:704-624-3390
Practice Address - Street 1:520 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MARSHVILLE
Practice Address - State:NC
Practice Address - Zip Code:28103-1197
Practice Address - Country:US
Practice Address - Phone:704-624-3388
Practice Address - Fax:704-624-3390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-27
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC32725261QP2300X
207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890132JMedicaid
0132JOtherBCBS
0132JOtherBCBS
2310459Medicare Oscar/Certification