Provider Demographics
NPI:1881144590
Name:SOUTHERN FAMILY MEDICINE, INC.
Entity type:Organization
Organization Name:SOUTHERN FAMILY MEDICINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:JARVIS
Authorized Official - Last Name:MICOLUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:LCMHCS
Authorized Official - Phone:704-953-4890
Mailing Address - Street 1:400 E STATESVILLE AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28115-2588
Mailing Address - Country:US
Mailing Address - Phone:704-360-8486
Mailing Address - Fax:704-230-4674
Practice Address - Street 1:400 E STATESVILLE AVE STE 200
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28115-2588
Practice Address - Country:US
Practice Address - Phone:704-360-8486
Practice Address - Fax:704-230-4674
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-05
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty