MEDICARE: BOMRAY MEDICAL CLINIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	261Q00000X	Clinic/Center
2	261QS1000X	Student Health Clinic/Center
3	261QU0200X	Urgent Care Clinic/Center
4	261QH0100X	Health Service Clinic/Center
5	261QP2300X	Primary Care Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1013974864
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOMRAY MEDICAL CLINIC

Provider Business Mailing Address
First Line	:	3627 BEATTIES FORD RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28216-3249
Country	:	US
Telephone Number	:	704-335-0806
Fax Number	:	704-334-2073

Provider Business Practice Location Address
First Line	:	3627 BEATTIES FORD RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28216-3249
Country	:	US
Telephone Number	:	704-335-0806
Fax Number	:	704-334-2073

Authorized Official
Title or Position	:	BILLING REPRESENTATIVE
Name	:	MRS. JERRI OLSZEWSKI
Credential	:
Telephone Number	:	704-335-0806

Provider Enumeration Date	:	04/26/2006
Last Update Date	:	07/20/2010

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Directions to “BOMRAY MEDICAL CLINIC ” Practice Location

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