Provider Demographics
NPI:1912968934
Name:FIRST FOUNDATION CLINIC OF THE CAROLINAS, INC.
Entity type:Organization
Organization Name:FIRST FOUNDATION CLINIC OF THE CAROLINAS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:THIRRFERN
Authorized Official - Middle Name:
Authorized Official - Last Name:JAMERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-923-0446
Mailing Address - Street 1:PO BOX 578
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:NC
Mailing Address - Zip Code:28034-0578
Mailing Address - Country:US
Mailing Address - Phone:704-923-0446
Mailing Address - Fax:704-923-8319
Practice Address - Street 1:107 N SUMMEY ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:NC
Practice Address - Zip Code:28034-1824
Practice Address - Country:US
Practice Address - Phone:704-923-0446
Practice Address - Fax:704-923-8319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-29
Last Update Date:2008-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0233UOtherBCBS
NC790233UMedicaid
NC2323099Medicare ID - Type Unspecified