Provider Demographics
NPI:1699960302
Name:PRIMARY CARE OF ST. PAULS, LLC
Entity type:Organization
Organization Name:PRIMARY CARE OF ST. PAULS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMED
Authorized Official - Middle Name:B
Authorized Official - Last Name:OSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-865-5177
Mailing Address - Street 1:P O BOX 9940
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28311-9940
Mailing Address - Country:US
Mailing Address - Phone:910-865-5177
Mailing Address - Fax:910-865-9400
Practice Address - Street 1:122 EAST BLUE STREET
Practice Address - Street 2:
Practice Address - City:ST. PAULS
Practice Address - State:NC
Practice Address - Zip Code:28384
Practice Address - Country:US
Practice Address - Phone:910-865-5177
Practice Address - Fax:910-865-9400
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRIMARY CARE OF ST. PAULS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-06
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
NC2002-01142207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5900350Medicaid
NC2345613Medicare PIN
NCG24183Medicare UPIN
NC5900350Medicaid