Provider Demographics
NPI:1881623023
Name:NORTH CAROLINA FAMILY DOCTOR, P.A.
Entity type:Organization
Organization Name:NORTH CAROLINA FAMILY DOCTOR, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:ASHLEY
Authorized Official - Last Name:WITHROW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-968-1985
Mailing Address - Street 1:1728 FORDHAM BLVD
Mailing Address - Street 2:151 RAMS PLAZA
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27514-2397
Mailing Address - Country:US
Mailing Address - Phone:919-968-1985
Mailing Address - Fax:919-942-0038
Practice Address - Street 1:1728 FORDHAM BLVD
Practice Address - Street 2:151 RAMS PLAZA
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-2397
Practice Address - Country:US
Practice Address - Phone:919-968-1985
Practice Address - Fax:919-942-0038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC27884261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCC86790Medicare UPIN