Basic Information
| Provider Information | |||||||||
| NPI: | 1083905079 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAROLINAS MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | LEVINE CHILDREN'S SPECIALTY CENTER - BALLANTYNE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 601372 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282601372 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 14214 BALLANTYNE LAKE RD | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282773372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046672680 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2011 | ||||||||
| LastUpdateDate: | 04/25/2011 | ||||||||
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| AuthorizedOfficialLastName: | UNDERWOOD | ||||||||
| AuthorizedOfficialFirstName: | DENNIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7043553147 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CAROLINAS MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.