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General NPI Number Information
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NPI Number | 1669664264
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Entity Type | Organization
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Legal Business Name | MOUNTAIN ISLAND FAMILY MEDICINE, PC
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Dates
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Enumeration Date | 08/16/2007
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Last Update Date | 02/02/2011
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Provider Practice Location Address
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Address Line | 10226 COULOAK DR SUITE 110
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City | CHARLOTTE
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State | NC
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Zip | 28216-7675
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Country | US
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Telephone | 704-399-1415
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Fax | 704-399-1415
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Provider Business Mailing Address
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Address Line | 10226 COULOAK DR SUITE 110
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City | CHARLOTTE
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State | NC
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Zip | 28216-7675
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Country | US
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Telephone | 704-399-1415
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Fax | 704-399-1415
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. CLAYTON R BAILEY
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Credential | MD
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Telephone | 704-399-1415
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | 125435
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License Number State | NC
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