Healthcare Provider Details

I. General information

NPI: 1518343573
Provider Name (Legal Business Name): THE FAMILY DOC BACK TO BASICS MEDICAL PRACTICE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2015
Last Update Date: 07/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1503 ELM STREET, SUITE C
SANFORD NC
27330
US

IV. Provider business mailing address

1503 ELM STREET, SUITE C
SANFORD NC
27330
US

V. Phone/Fax

Practice location:
  • Phone: 919-895-6339
  • Fax: 919-590-1981
Mailing address:
  • Phone: 919-895-6339
  • Fax: 919-590-1981

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number23907
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number23907
License Number StateNC

VIII. Authorized Official

Name: DR. ROBERT WILLIAM PATTERSON
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 919-895-6339