MEDICARE: METROLINA MEDICAL CLINIC, PLLC

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	363LP2300X	Primary Care Nurse Practitioner	5008453	NC
2	207R00000X	Internal Medicine Physician		NC

General Provider Information

NPI Number	:	1447790662
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	METROLINA MEDICAL CLINIC, PLLC

Provider Business Mailing Address
First Line	:	1510 ORCHARD LAKE DR
Second Line	:	SUITE A
City	:	CHARLOTTE
State	:	NC
Zip	:	28270-1567
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1510 ORCHARD LAKE DR
Second Line	:	SUITE A
City	:	CHARLOTTE
State	:	NC
Zip	:	28270-1567
Country	:	US
Telephone Number	:	704-864-6584
Fax Number	:

Authorized Official
Title or Position	:	BILLING MANAGER
Name	:	ZINA FALLS
Credential	:
Telephone Number	:	704-866-4607

Provider Enumeration Date	:	03/07/2017
Last Update Date	:	03/07/2017

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