Basic Information
| Provider Information | |||||||||
| NPI: | 1215685433 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAROLINAS PHYSICIANS NETWORK INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ATRIUM HEALTH LIVEWELL CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 19305 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282199305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046310002 | ||||||||
| FaxNumber: | 7044463569 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 E GROVER ST STE 2000 | ||||||||
| Address2: | |||||||||
| City: | SHELBY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281503917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9804873022 | ||||||||
| FaxNumber: | 7044463575 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2022 | ||||||||
| LastUpdateDate: | 03/16/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RISSMILLER | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | CLIFTON | ||||||||
| AuthorizedOfficialTitleorPosition: | EVP & CHIEF PHYSICIAN EXECUTIVE | ||||||||
| AuthorizedOfficialTelephone: | 7044463507 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CAROLINAS PHYSICIANS NETWORK INC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 03/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.