Healthcare Provider Details

I. General information

NPI: 1386947828
Provider Name (Legal Business Name): CHARLOTTE MEDICAL CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2010
Last Update Date: 03/02/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10650 PARK RD STE 300
CHARLOTTE NC
28210-8538
US

IV. Provider business mailing address

PO BOX 19305
CHARLOTTE NC
28219-9305
US

V. Phone/Fax

Practice location:
  • Phone: 704-667-3960
  • Fax:
Mailing address:
  • Phone: 704-631-0002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: THOMAS LAYMON
Title or Position: SENIOR VICE PRESIDENT
Credential:
Phone: 704-446-8250