MEDICARE: COMMUNITY CARE SPECIALISTS & URGENT CARE LLC

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	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1649583519
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMUNITY CARE SPECIALISTS & URGENT CARE LLC

Provider Business Mailing Address
First Line	:	3721 LYNN RD
Second Line	:	SUITE 104
City	:	RALEIGH
State	:	NC
Zip	:	27613-3854
Country	:	US
Telephone Number	:	919-758-8610
Fax Number	:	919-758-8613

Provider Business Practice Location Address
First Line	:	3721 LYNN RD
Second Line	:	SUITE 104
City	:	RALEIGH
State	:	NC
Zip	:	27613-3854
Country	:	US
Telephone Number	:	919-758-8610
Fax Number	:	919-758-8613

Authorized Official
Title or Position	:	CEO
Name	:	ANITA L JACKSON
Credential	:	MD
Telephone Number	:	919-758-8610

Provider Enumeration Date	:	07/21/2010
Last Update Date	:	07/21/2010

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