Healthcare Provider Details

I. General information

NPI: 1881663227
Provider Name (Legal Business Name): CHICORA MEDICAL GROUP PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 03/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 MEDICAL CAMPUS DR STE 106B
SUPPLY NC
28462
US

IV. Provider business mailing address

PO BOX 2528
SHALLOTTE NC
28459
US

V. Phone/Fax

Practice location:
  • Phone: 910-754-8600
  • Fax: 910-755-2364
Mailing address:
  • Phone: 910-754-8600
  • Fax: 910-755-2364

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: DR. BERNARD LEROY LANGSTON III
Title or Position: PRESIDENT
Credential: MD
Phone: 910-754-8731