MEDICARE: LUKE MEDICAL CLINIC, P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	9401198	NC

General Provider Information

NPI Number	:	1396918413
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LUKE MEDICAL CLINIC, P.A.

Provider Business Mailing Address
First Line	:	125 W CATAWBA AVE
Second Line	:
City	:	MT HOLLY
State	:	NC
Zip	:	28120-1601
Country	:	US
Telephone Number	:	704-827-3014
Fax Number	:	704-822-9114

Provider Business Practice Location Address
First Line	:	125 W CATAWBA AVE
Second Line	:
City	:	MT HOLLY
State	:	NC
Zip	:	28120-1601
Country	:	US
Telephone Number	:	704-827-3014
Fax Number	:	704-822-9114

Authorized Official
Title or Position	:	OWNER
Name	:	GREGORY L GLASS
Credential	:	M.D.
Telephone Number	:	704-827-3014

Provider Enumeration Date	:	04/09/2008
Last Update Date	:	11/08/2010

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