Basic Information
| Provider Information | |||||||||
| NPI: | 1215939947 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRESBYTERIAN REGIONAL HEALTHCARE CORPORATION | ||||||||
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| OtherOrganizationName: | ANDRINOPOULOS OBSTETRICS & GYNECOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 BALDWIN AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282043227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043849113 | ||||||||
| FaxNumber: | 7043849118 | ||||||||
| Practice Location | |||||||||
| Address1: | 2028 RANDOLPH RD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282071216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043725800 | ||||||||
| FaxNumber: | 7043725657 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | EASTERLING | ||||||||
| AuthorizedOfficialFirstName: | PATRICK | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 7043849113 | ||||||||
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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 | 207V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 5900425 | 05 | NC | MEDICAID |