Chicora Medical Group PA
Organization Active NPI Family Medicine Physician · Supply, NC
NPI 1881663227 · NPPES record last updated Mar 11, 2008
Key facts
- NPI
- 1881663227
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Family Medicine Physician 207Q00000X
- Legal business name
- CHICORA MEDICAL GROUP PA
- Practice address
- 20 Medical Campus Dr
Ste 106B
Supply, NC 28462 - Phone
- (910) 754-8600
- Fax
- (910) 755-2364
- NPI assigned
- Mar 17, 2006
- Organization subpart
- No
Authorized official
- Name
- Dr. Bernard Leroy Langston III, MD
- Title
- President
- Phone
- (910) 754-8731
Corporate family (same tax ID) 1
Practitioners 15
-
Eileen Marie Ceponis, FNP C
-
Tiffany Horton, PA-C
-
Amy Sue Kelly, PA-C
-
Heather Merrow, PAC
-
Cathy Marie Sellers, FNPC
-
Misty Justus, PA
-
Viki Lambertus, FNP
National Provider Directory
- Tax ID family
- Brunswick Speciality Services
Locations
20 Medical Campus Dr NW
Ste 106B
Supply, NC 28462
Phone (910) 754-8600
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician |
207Q00000X | Yes |
Addresses
Primary practice location
20 Medical Campus Dr
Ste 106B
Supply, NC 28462
Mailing address
PO Box 2528
Shallotte, NC 28459
Phone (910) 754-8600
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 5900666 | Medicaid | NC |
Other names
- Brunswick Speciality Services
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All providers in Supply, NC · Family Medicine Physician in North Carolina
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Mar 11, 2008. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.