Provider Demographics
NPI:1417241373
Name:BOMAR, REBECCA PAGE (MD)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:PAGE
Last Name:BOMAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 MEDICAL PARK DR
Practice Address - Street 2:STE 330
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2982
Practice Address - Country:US
Practice Address - Phone:704-403-1308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-07
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2021-02672207R00000X, 207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCLL 33611OtherSOUTH CAROLINA DEPARTMENT OF LABOR, LICENSING AND REGULATION
NY286207OtherNEW YORK DEPARTMENT OF LABOR, LICENSING AND REGULATION