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General NPI Number Information
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NPI Number | 1073562757
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Entity Type | Organization
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Legal Business Name | MID-ATLANTIC EMERGENCY MEDICAL ASSOCIATES, PLLC
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Dates
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Enumeration Date | 05/09/2006
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Last Update Date | 07/03/2018
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Provider Practice Location Address
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Address Line | 501 S SHARON AMITY RD STE 300
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City | CHARLOTTE
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State | NC
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Zip | 28211
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Country | US
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Telephone | 704-377-2424
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Fax | 704-377-2687
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Provider Business Mailing Address
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Address Line | 501 S SHARON AMITY RD STE 300
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City | CHARLOTTE
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State | NC
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Zip | 28211-0035
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Country | US
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Telephone | 704-377-2424
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Fax | 704-377-2687
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Authorized Official
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Title or Position | CHIEF OPERATING OFFICER
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Name | MICHAEL WAYNE ICENHOUR
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Credential |
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Telephone | 704-319-5822
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number |
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License Number State | NC
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