MEDICARE: PHYSICIAN MANAGEMENT SERVICES OF NORTH CAROLINA, LLC

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	:	1831772748
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHYSICIAN MANAGEMENT SERVICES OF NORTH CAROLINA, LLC

Provider Business Mailing Address
First Line	:	3113 LAWTON RD STE 250
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32803-3517
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7490 ANDREW JACKSON HWY SW
Second Line	:
City	:	CERRO GORDO
State	:	NC
Zip	:	28430-9258
Country	:	US
Telephone Number	:	888-829-8550
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BRETT KENEFICK
Credential	:
Telephone Number	:	888-829-8550

Provider Enumeration Date	:	04/29/2021
Last Update Date	:	04/29/2021

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