MEDICARE: FAYETTEVILLE GERIATRIC & INTERNAL MEDICINE CLINIC 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	207R00000X	Internal 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
2	1163K	OTHER		BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1649373788
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAYETTEVILLE GERIATRIC & INTERNAL MEDICINE CLINIC PA

Provider Business Mailing Address
First Line	:	PO BOX 1689
Second Line	:
City	:	ETOWAH
State	:	NC
Zip	:	28729-1689
Country	:	US
Telephone Number	:	828-891-5524
Fax Number	:	828-891-4069

Provider Business Practice Location Address
First Line	:	3616 CAPE CENTER DR
Second Line	:	SUITE A
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28304
Country	:	US
Telephone Number	:	910-868-6730
Fax Number	:	910-829-9649

Authorized Official
Title or Position	:	DOCTOR
Name	:	MOHAMMED RAHMAN
Credential	:	MD
Telephone Number	:	910-868-6730

Provider Enumeration Date	:	09/06/2006
Last Update Date	:	06/11/2014

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Directions to “FAYETTEVILLE GERIATRIC & INTERNAL MEDICINE CLINIC PA ” Practice Location

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