Basic Information
| Provider Information | |||||||||
| NPI: | 1194167338 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORTHOCAROLINA, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4601 PARK RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282093239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043232000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1914 W PARK DR | ||||||||
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| City: | NORTH WILKESBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286593563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043232000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2013 | ||||||||
| LastUpdateDate: | 07/29/2013 | ||||||||
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| AuthorizedOfficialLastName: | SHEAR | ||||||||
| AuthorizedOfficialFirstName: | BRENT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7043232000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 28865 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207X00000X | 28865 | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 8901619 | 05 | NC | MEDICAID |