Healthcare Provider Details

I. General information

NPI: 1053503763
Provider Name (Legal Business Name): MED FIRST IMMEDIATE CARE & FAMILY PRACTICE, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2007
Last Update Date: 12/08/2023
Certification Date: 12/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 RICHLANDS HWY STE 6
JACKSONVILLE NC
28540-3606
US

IV. Provider business mailing address

1616 E MILLBROOK RD STE 110
RALEIGH NC
27609-4971
US

V. Phone/Fax

Practice location:
  • Phone: 910-455-7888
  • Fax: 910-455-1403
Mailing address:
  • Phone: 919-341-4016
  • Fax: 910-346-1907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number9801392
License Number StateNC

VIII. Authorized Official

Name: MR. PAUL FENECK
Title or Position: CEO
Credential:
Phone: 919-341-4016