Basic Information
| Provider Information | |||||||||
| NPI: | 1104809730 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAROLINA CARDIOVASCULAR SURGICAL ASSOCIATES P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3000 NEW BERN AVE | ||||||||
| Address2: | STE 1100 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192316333 | ||||||||
| FaxNumber: | 9192316334 | ||||||||
| Practice Location | |||||||||
| Address1: | 3000 NEW BERN AVE | ||||||||
| Address2: | STE 1100 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192316333 | ||||||||
| FaxNumber: | 9192316334 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2005 | ||||||||
| LastUpdateDate: | 12/16/2009 | ||||||||
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| AuthorizedOfficialLastName: | NEWELL | ||||||||
| AuthorizedOfficialFirstName: | CAROL | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9192316333 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | CEO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 01229 | 01 | NC | BCBS | OTHER | 8901229 | 05 | NC | MEDICAID |