Healthcare Provider Details

I. General information

NPI: 1851561112
Provider Name (Legal Business Name): RUTH S FAIRCLOTH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2008
Last Update Date: 01/29/2024
Certification Date: 01/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 ROBESON ST STE 410
FAYETTEVILLE NC
28301-5520
US

IV. Provider business mailing address

PO BOX 896263
CHARLOTTE NC
28289-6263
US

V. Phone/Fax

Practice location:
  • Phone: 910-615-1688
  • Fax: 910-321-6254
Mailing address:
  • Phone: 910-615-4815
  • Fax: 910-615-9761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number24472
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number2022-01576
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: