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General NPI Number Information
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NPI Number | 1508386640
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Entity Type | Organization
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Legal Business Name | FIRST MED PC
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Dates
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Enumeration Date | 06/20/2017
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Last Update Date | 06/20/2017
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Provider Practice Location Address
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Address Line | 1795 DR FRANK GASTON BLVD
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City | ROCK HILL
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State | SC
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Zip | 29732-1190
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Country | US
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Telephone | 516-849-8385
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Fax | 516-830-3520
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Provider Business Mailing Address
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Address Line | 8022 PROVIDENCE RD STE 500-119
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City | CHARLOTTE
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State | NC
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Zip | 28277-9719
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Country | US
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Telephone | 516-849-8385
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Fax | 516-830-3520
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Authorized Official
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Title or Position | CEO
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Name | NDI JOHNNIE MADUAKO
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Credential | MD
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Telephone | 516-849-8385
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | MD37960
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License Number State | SC
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