Provider Demographics
NPI:1912228347
Name:INTERNATIONAL CLINIC OF THE CAROLINAS PLLC
Entity Type:Organization
Organization Name:INTERNATIONAL CLINIC OF THE CAROLINAS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:TONOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-782-4884
Mailing Address - Street 1:2406 BLUE RIDGE RD
Mailing Address - Street 2:SUITE 170
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-6678
Mailing Address - Country:US
Mailing Address - Phone:919-782-4884
Mailing Address - Fax:919-782-4885
Practice Address - Street 1:2406 BLUE RIDGE RD
Practice Address - Street 2:SUITE 170
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-6678
Practice Address - Country:US
Practice Address - Phone:919-782-4884
Practice Address - Fax:919-782-4885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-21
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200801582207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2023140CMedicare PIN