| Southern Family Medicine, Inc. | |
|
400 E Statesville Ave Ste 200 Mooresville NC 28115-2588 | |
| (704) 360-8486 | |
| (704) 230-4674 |
| Full Name | Southern Family Medicine, Inc. |
|---|---|
| Speciality | Family Medicine |
| Location | 400 E Statesville Ave Ste 200, Mooresville, North Carolina |
| Authorized Official Name and Position | Angela Jarvis Micolucci (CEO) |
| Authorized Official Contact | 7049534890 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Southern Family Medicine, Inc. 400 E Statesville Ave Ste 200 Mooresville NC 28115-2588 Ph: (704) 360-8486 | Southern Family Medicine, Inc. 400 E Statesville Ave Ste 200 Mooresville NC 28115-2588 Ph: (704) 360-8486 |
| NPI Number | 1881144590 |
|---|---|
| Provider Enumeration Date | 10/05/2016 |
| Last Update Date | 08/19/2024 |
| Certification Date | 08/19/2024 |
| Medicare PECOS PAC ID | 0840558342 |
|---|---|
| Medicare Enrollment ID | O20171211000249 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1881144590 | NPI | - | NPPES |
| Provider Name | Bethany R Basnett |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1487718938 PECOS PAC ID: 9830294289 Enrollment ID: I20070413000463 |
| Provider Name | Anita J Vaughan |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1710014022 PECOS PAC ID: 9931299807 Enrollment ID: I20071214000642 |
| Provider Name | Aimee Culler |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1215206214 PECOS PAC ID: 4486998051 Enrollment ID: I20190301000752 |
| Provider Name | Jacquelyn Dwelle Mcginnis |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1750922779 PECOS PAC ID: 2365878824 Enrollment ID: I20200203000583 |
| Provider Name | Meredith Ashley Oldham Cullop |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1194312496 PECOS PAC ID: 9537572649 Enrollment ID: I20210111001371 |
| Provider Name | Jelena Mckeithan |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1245985092 PECOS PAC ID: 9032595905 Enrollment ID: I20220929001669 |
| Provider Name | Angela Jarvis Micolucci |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1740434315 PECOS PAC ID: 0941349914 Enrollment ID: I20240307000915 |
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