Healthcare Provider Details

I. General information

NPI: 1700296951
Provider Name (Legal Business Name): FIRST FAMILY MEDICAL LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2014
Last Update Date: 04/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1928 RANDOLPH RD STE 206
CHARLOTTE NC
28207-1105
US

IV. Provider business mailing address

1928 RANDOLPH RD STE 206
CHARLOTTE NC
28207-1105
US

V. Phone/Fax

Practice location:
  • Phone: 704-332-3350
  • Fax:
Mailing address:
  • Phone: 704-332-3350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2006-01193
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2006-01193
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code207RA0000X
TaxonomyAdolescent Medicine (Internal Medicine) Physician
License Number2006-01193
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2006-01193
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number2006-01193
License Number StateNC
# 6
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number2006-01193
License Number StateNC
# 7
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number2006-01193
License Number StateNC

VIII. Authorized Official

Name: MICHAEL NETTLES
Title or Position: OFFICE MANAGER
Credential:
Phone: 704-332-3350