Healthcare Provider Details

I. General information

NPI: 1780629154
Provider Name (Legal Business Name): CLINTON MEDICAL CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 07/08/2022
Certification Date: 07/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 FAIRVIEW ST
CLINTON NC
28328-2399
US

IV. Provider business mailing address

403 FAIRVIEW ST
CLINTON NC
28328-2399
US

V. Phone/Fax

Practice location:
  • Phone: 910-592-6011
  • Fax: 910-592-0811
Mailing address:
  • Phone: 910-592-6011
  • Fax: 910-592-0811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNC
# 6
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW Q. ROBINSON
Title or Position: PRACTICE ADMINISTRATOR
Credential: MBA
Phone: 910-590-0619