Provider Demographics
NPI:1215165659
Name:MARIETTA MEDICAL CLINIC PA
Entity type:Organization
Organization Name:MARIETTA MEDICAL CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:K
Authorized Official - Last Name:AGUNOBI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-866-8030
Mailing Address - Street 1:401 S MARIETTA ST
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28052-4331
Mailing Address - Country:US
Mailing Address - Phone:704-866-8030
Mailing Address - Fax:704-866-8717
Practice Address - Street 1:401 S MARIETTA ST
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28052-4331
Practice Address - Country:US
Practice Address - Phone:704-866-8030
Practice Address - Fax:704-866-8717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-24
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5950793Medicaid