MEDICARE: SOUTHERN CLINICS AND URGENT CARE PA

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1134108905
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN CLINICS AND URGENT CARE PA

Provider Business Mailing Address
First Line	:	PO BOX 550490
Second Line	:
City	:	GASTONIA
State	:	NC
Zip	:	28055-0490
Country	:	US
Telephone Number	:	704-865-2755
Fax Number	:	704-865-5013

Provider Business Practice Location Address
First Line	:	502 W KING ST
Second Line	:	LL 20
City	:	KINGS MOUNTAIN
State	:	NC
Zip	:	28086-3362
Country	:	US
Telephone Number	:	704-865-2755
Fax Number	:	704-865-5013

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. AUGUSTINE R EZE
Credential	:	M.D.
Telephone Number	:	704-865-2755

Provider Enumeration Date	:	01/11/2006
Last Update Date	:	08/22/2020

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