Provider Demographics
NPI:1396049060
Name:ARCHDALE FAMILY PRACTICE PA
Entity type:Organization
Organization Name:ARCHDALE FAMILY PRACTICE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:CRAIG
Authorized Official - Last Name:BECK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-861-4110
Mailing Address - Street 1:11635 N MAIN ST STE E
Mailing Address - Street 2:
Mailing Address - City:ARCHDALE
Mailing Address - State:NC
Mailing Address - Zip Code:27263-3271
Mailing Address - Country:US
Mailing Address - Phone:336-861-4110
Mailing Address - Fax:336-861-4295
Practice Address - Street 1:11635 N MAIN ST STE E
Practice Address - Street 2:
Practice Address - City:ARCHDALE
Practice Address - State:NC
Practice Address - Zip Code:27263-3271
Practice Address - Country:US
Practice Address - Phone:336-861-4110
Practice Address - Fax:336-861-4295
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-10
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC30119207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8914271Medicaid
NC8914271Medicaid