Provider Demographics
NPI:1306175476
Name:MECKLENBURG MEDICAL GROUP
Entity type:Organization
Organization Name:MECKLENBURG MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:FORD
Authorized Official - Last Name:LAYMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-631-0002
Mailing Address - Street 1:PO BOX 601643
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1643
Mailing Address - Country:US
Mailing Address - Phone:704-302-9700
Mailing Address - Fax:704-302-9701
Practice Address - Street 1:1550 FAULK ST
Practice Address - Street 2:SUITE 1500
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112-5086
Practice Address - Country:US
Practice Address - Phone:704-302-9700
Practice Address - Fax:704-302-9701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-18
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207RH0003X
NC332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNPB352Medicaid
NC5914037Medicaid
NC7705296OtherMEDICAID DME
NC7705296OtherMEDICAID DME
SCNPB352Medicaid