Healthcare Provider Details

I. General information

NPI: 1619908233
Provider Name (Legal Business Name): ROXBORO FAMILY MEDICINE & IMMEDIATE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 06/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

228 S MADISON BLVD
ROXBORO NC
27573-5428
US

IV. Provider business mailing address

PO BOX 61474
DURHAM NC
27715-1474
US

V. Phone/Fax

Practice location:
  • Phone: 336-598-5480
  • Fax: 336-598-5482
Mailing address:
  • Phone: 919-544-6318
  • Fax: 919-544-6336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: LISA P SHOCK
Title or Position: PRESIDENT
Credential: PA
Phone: 336-598-5480