Provider Demographics
NPI:1740499714
Name:CAROLINA FAMILY MEDICINE & URGENT CARE PA
Entity type:Organization
Organization Name:CAROLINA FAMILY MEDICINE & URGENT CARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER/DELEGATED OFFICIAL
Authorized Official - Prefix:MRS
Authorized Official - First Name:CODEY
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-871-9731
Mailing Address - Street 1:1503 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28625-4301
Mailing Address - Country:US
Mailing Address - Phone:704-871-9731
Mailing Address - Fax:704-871-1105
Practice Address - Street 1:1503 E BROAD ST
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625-4301
Practice Address - Country:US
Practice Address - Phone:704-871-9731
Practice Address - Fax:704-871-1105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200001772371207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89014W8Medicaid
NC014W8OtherBCBSNC
NC2334714Medicare PIN