MEDICARE: MAIN STREET FAMILY PRACTICE OF CHINA GROVE PC

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

General Provider Information

NPI Number	:	1619279247
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAIN STREET FAMILY PRACTICE OF CHINA GROVE PC

Provider Business Mailing Address
First Line	:	302 S MAIN ST
Second Line	:
City	:	CHINA GROVE
State	:	NC
Zip	:	28023-2471
Country	:	US
Telephone Number	:	704-857-8769
Fax Number	:	704-857-8779

Provider Business Practice Location Address
First Line	:	302 S MAIN ST
Second Line	:
City	:	CHINA GROVE
State	:	NC
Zip	:	28023-2471
Country	:	US
Telephone Number	:	704-857-8769
Fax Number	:	704-857-8779

Authorized Official
Title or Position	:	OWNER
Name	:	MS. KIM PURCELL-REID
Credential	:	PA-C
Telephone Number	:	704-857-8769

Provider Enumeration Date	:	12/02/2010
Last Update Date	:	12/02/2010

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Directions to “MAIN STREET FAMILY PRACTICE OF CHINA GROVE PC ” Practice Location

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