Provider Demographics
NPI:1285873018
Name:FAYETTEVILLE MEDICAL CLINIC, PC
Entity type:Organization
Organization Name:FAYETTEVILLE MEDICAL CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AGODICHI
Authorized Official - Middle Name:U
Authorized Official - Last Name:NWOSU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-483-7506
Mailing Address - Street 1:3613 RAEFORD RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-2113
Mailing Address - Country:US
Mailing Address - Phone:910-483-7506
Mailing Address - Fax:910-483-1749
Practice Address - Street 1:3613 RAEFORD RD
Practice Address - Street 2:SUITE C
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-2113
Practice Address - Country:US
Practice Address - Phone:910-483-7506
Practice Address - Fax:910-483-1749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-18
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty