Basic Information
| Provider Information | |||||||||
| NPI: | 1356517700 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MDFAMILY MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 138 S CHERRY ST | ||||||||
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| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271015272 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4530 PARK RD STE 200 | ||||||||
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| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282093790 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045276322 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2008 | ||||||||
| LastUpdateDate: | 05/06/2008 | ||||||||
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| AuthorizedOfficialLastName: | SANDERS | ||||||||
| AuthorizedOfficialFirstName: | AUDREY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF OPERATIONS OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9196764714 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.