Healthcare Provider Details

I. General information

NPI: 1669664264
Provider Name (Legal Business Name): MOUNTAIN ISLAND FAMILY MEDICINE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2007
Last Update Date: 02/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10226 COULOAK DR SUITE 110
CHARLOTTE NC
28216-7675
US

IV. Provider business mailing address

10226 COULOAK DR SUITE 110
CHARLOTTE NC
28216-7675
US

V. Phone/Fax

Practice location:
  • Phone: 704-399-1415
  • Fax: 704-399-1415
Mailing address:
  • Phone: 704-399-1415
  • Fax: 704-399-1415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number125435
License Number StateNC

VIII. Authorized Official

Name: DR. CLAYTON R BAILEY
Title or Position: PRESIDENT
Credential: MD
Phone: 704-399-1415