MEDICARE: NC IMMUNOLOGY, PC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	261QI0500X	Infusion Therapy Clinic/Center
2	207RR0500X	Rheumatology Physician
3	207RG0100X	Gastroenterology Physician
4	207K00000X	Allergy & Immunology Physician

General Provider Information

NPI Number	:	1619785920
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NC IMMUNOLOGY, PC

Provider Business Mailing Address
First Line	:	1414 FERN CREEK DR
Second Line	:
City	:	STATESVILLE
State	:	NC
Zip	:	28625-9376
Country	:	US
Telephone Number	:	704-873-5055
Fax Number	:	704-873-5025

Provider Business Practice Location Address
First Line	:	1414 FERN CREEK DR
Second Line	:
City	:	STATESVILLE
State	:	NC
Zip	:	28625-9376
Country	:	US
Telephone Number	:	704-873-5055
Fax Number	:	704-873-5025

Authorized Official
Title or Position	:	OFFICE ADMINISTRATOR
Name	:	ANNA M JACKSON
Credential	:
Telephone Number	:	704-873-5055

Provider Enumeration Date	:	12/19/2024
Last Update Date	:	06/10/2026

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