MEDICARE: EMMETT C. MATHEWS, JR, MD PA

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	261Q00000X	Clinic/Center	33089	NC

General Provider Information

NPI Number	:	1497995450
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMMETT C. MATHEWS, JR, MD PA

Provider Business Mailing Address
First Line	:	1928 RANDOLPH RD
Second Line	:	SUITE 215
City	:	CHARLOTTE
State	:	NC
Zip	:	28207-1105
Country	:	US
Telephone Number	:	704-332-3632
Fax Number	:	704-332-3891

Provider Business Practice Location Address
First Line	:	1928 RANDOLPH RD
Second Line	:	SUITE 215
City	:	CHARLOTTE
State	:	NC
Zip	:	28207-1105
Country	:	US
Telephone Number	:	704-332-3632
Fax Number	:	704-332-3891

Authorized Official
Title or Position	:	OWNER
Name	:	DR. EMMETT C MATHEWS
Credential	:	M.D.
Telephone Number	:	704-332-3632

Provider Enumeration Date	:	03/03/2009
Last Update Date	:	03/26/2009

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