Basic Information
| Provider Information | |||||||||
| NPI: | 1104836022 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCORD | ||||||||
| FirstName: | CARL | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 602373 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282602373 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 310 LONG SHOALS RD | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | ARDEN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287048794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282134444 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 05/05/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME142535 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 18832 | SC | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 2014-02080 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | L8996 | 01 | FL | FL MEDICARE | OTHER | 188326 | 05 | SC | MEDICAID |