Healthcare Provider Details

I. General information

NPI: 1306175476
Provider Name (Legal Business Name): MECKLENBURG MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2009
Last Update Date: 08/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 FAULK ST SUITE 1500
MONROE NC
28112-5086
US

IV. Provider business mailing address

PO BOX 601643
CHARLOTTE NC
28260-1643
US

V. Phone/Fax

Practice location:
  • Phone: 704-302-9700
  • Fax: 704-302-9701
Mailing address:
  • Phone: 704-302-9700
  • Fax: 704-302-9701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNC

VIII. Authorized Official

Name: MR. THOMAS FORD LAYMON
Title or Position: SENIOR VICE PRESIDENT
Credential:
Phone: 704-631-0002