Healthcare Provider Details

I. General information

NPI: 1851684435
Provider Name (Legal Business Name): JACOB MILLER MCGRATH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2011
Last Update Date: 09/29/2023
Certification Date: 09/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HAWTHORNE LN
CHARLOTTE NC
28204-2515
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 704-384-9414
  • Fax: 704-384-5735
Mailing address:
  • Phone: 704-384-1246
  • Fax: 704-384-6072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number1.054585
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2016-00422
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: