Healthcare Provider Details

I. General information

NPI: 1033565007
Provider Name (Legal Business Name): STAR MEDICAL CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2016
Last Update Date: 06/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

461 WESTERN BLVD STE 122
JACKSONVILLE NC
28546-7637
US

IV. Provider business mailing address

461 WESTERN BLVD STE 122
JACKSONVILLE NC
28546-7637
US

V. Phone/Fax

Practice location:
  • Phone: 910-333-0283
  • Fax: 910-333-0513
Mailing address:
  • Phone: 910-333-0283
  • Fax: 910-333-0513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. KEVIN R SCYOC
Title or Position: CEO
Credential:
Phone: 910-330-2335