Provider Demographics
NPI:1881998748
Name:DEACON MED PA
Entity type:Organization
Organization Name:DEACON MED PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:I
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-545-1515
Mailing Address - Street 1:702 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RANDLEMAN
Mailing Address - State:NC
Mailing Address - Zip Code:27317-2102
Mailing Address - Country:US
Mailing Address - Phone:336-545-1515
Mailing Address - Fax:336-545-4505
Practice Address - Street 1:702 S MAIN ST
Practice Address - Street 2:
Practice Address - City:RANDLEMAN
Practice Address - State:NC
Practice Address - Zip Code:27317-2102
Practice Address - Country:US
Practice Address - Phone:336-545-1515
Practice Address - Fax:336-545-4505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-06
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care