Provider Demographics
NPI:1952543688
Name:GENERAL MEDICAL CLINIC,PA
Entity Type:Organization
Organization Name:GENERAL MEDICAL CLINIC,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAMIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:WAYNICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-633-0413
Mailing Address - Street 1:PO BOX 5568
Mailing Address - Street 2:
Mailing Address - City:ASHEBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27204-5568
Mailing Address - Country:US
Mailing Address - Phone:336-633-0413
Mailing Address - Fax:336-633-0411
Practice Address - Street 1:3505 N ROXBORO ST STE C
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-2767
Practice Address - Country:US
Practice Address - Phone:919-383-0003
Practice Address - Fax:919-382-0042
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GENERAL MEDICAL CLINIC,PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-03-26
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9700286261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5907888Medicaid
NC2323787Medicare PIN