Healthcare Provider Details

I. General information

NPI: 1821059650
Provider Name (Legal Business Name): POLYCLINIC MEDICAL CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 06/08/2020
Certification Date: 06/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9705 NORTHEAST PKWY STE 400
MATTHEWS NC
28105-9704
US

IV. Provider business mailing address

9705 NORTHEAST PKWY STE 400
MATTHEWS NC
28105-9704
US

V. Phone/Fax

Practice location:
  • Phone: 704-844-8971
  • Fax: 704-844-8972
Mailing address:
  • Phone: 704-844-8971
  • Fax: 704-844-8972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25646
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number2000-01378
License Number StateNC

VIII. Authorized Official

Name: MRS. JOSI BRAZ GARUBA
Title or Position: CEO
Credential:
Phone: 704-844-8971