MEDICARE: SOUTHERN CLINIC AND URGT CAR

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

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	:	1497734271
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN CLINIC AND URGT CAR

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	:	3420 FILBERT HWY
Second Line	:
City	:	CLOVER
State	:	SC
Zip	:	29710-5602
Country	:	US
Telephone Number	:	803-222-0600
Fax Number	:	803-222-6119

Authorized Official
Title or Position	:	PRESIDENT
Name	:	AUGUSTINE R EZE
Credential	:	MD
Telephone Number	:	704-865-2755

Provider Enumeration Date	:	01/11/2006
Last Update Date	:	04/20/2008

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Directions to “SOUTHERN CLINIC AND URGT CAR ” Practice Location

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