Basic Information
| Provider Information | |||||||||
| NPI: | 1073562757 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MID-ATLANTIC EMERGENCY MEDICAL ASSOCIATES, PLLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 501 S SHARON AMITY RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282110035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043772424 | ||||||||
| FaxNumber: | 7043772687 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 S SHARON AMITY RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043772424 | ||||||||
| FaxNumber: | 7043772687 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2006 | ||||||||
| LastUpdateDate: | 07/03/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ICENHOUR | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | WAYNE | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7043195822 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0294W | 01 | NC | BCBSNC | OTHER | 89-016RM | 05 | NC | MEDICAID | CI1307 | 01 | NC | RR MEDICARE | OTHER | QPA372 | 05 | SC | MEDICAID | 89-0294W | 05 | NC | MEDICAID | 89-0295G | 05 | NC | MEDICAID | NPA807 | 05 | SC | MEDICAID | QPA373 | 05 | SC | MEDICAID | 89-0295H | 05 | NC | MEDICAID | NPA822 | 05 | SC | MEDICAID | 89-01401 | 05 | NC | MEDICAID |