Basic Information
| Provider Information | |||||||||
| NPI: | 1134265325 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY MEDICAL ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 751514 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282751514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437926200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 171 ASHLEY AVE | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294250001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437921414 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | RAE | ||||||||
| AuthorizedOfficialFirstName: | KARYN | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8438761344 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 363LS0200X | X | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | School |
ID Information
| ID | Type | State | Issuer | Description | GP4581 | 05 | SC | MEDICAID |