Healthcare Provider Details

I. General information

NPI: 1356517700
Provider Name (Legal Business Name): MDFAMILY MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2008
Last Update Date: 05/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4530 PARK RD STE 200
CHARLOTTE NC
28209-3790
US

IV. Provider business mailing address

138 S CHERRY ST
WINSTON SALEM NC
27101-5272
US

V. Phone/Fax

Practice location:
  • Phone: 704-527-6322
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: AUDREY SANDERS
Title or Position: CHIEF OPERATIONS OFFICER
Credential:
Phone: 919-676-4714