=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225139660
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTH MECKLENBURG FAMILY PRACTICE GROUP PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2006
-----------------------------------------------------
Last Update Date | 07/09/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6111 RUMPLE RD
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28262
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-596-5067
-----------------------------------------------------
Fax | 704-599-9458
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6111 RUMPLE RD
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28262
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-596-5067
-----------------------------------------------------
Fax | 704-599-9458
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD PRESIDENT
-----------------------------------------------------
Name | JEROME HOWARD
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 704-596-5067
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | NC18523
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------