Provider Demographics
NPI:1649373788
Name:FAYETTEVILLE GERIATRIC & INTERNAL MEDICINE CLINIC PA
Entity type:Organization
Organization Name:FAYETTEVILLE GERIATRIC & INTERNAL MEDICINE CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMMED
Authorized Official - Middle Name:
Authorized Official - Last Name:RAHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-868-6730
Mailing Address - Street 1:PO BOX 1689
Mailing Address - Street 2:
Mailing Address - City:ETOWAH
Mailing Address - State:NC
Mailing Address - Zip Code:28729-1689
Mailing Address - Country:US
Mailing Address - Phone:828-891-5524
Mailing Address - Fax:828-891-4069
Practice Address - Street 1:3616 CAPE CENTER DR
Practice Address - Street 2:SUITE A
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304
Practice Address - Country:US
Practice Address - Phone:910-868-6730
Practice Address - Fax:910-829-9649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891163KMedicaid
1163KOtherBLUE CROSS BLUE SHIELD
NC891163KMedicaid
NC2259327AMedicare PIN