Basic Information
| Provider Information | |||||||||
| NPI: | 1346446309 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH CROSS MEDICAL CENTER PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17705 SPRING WINDS DR | ||||||||
| Address2: | |||||||||
| City: | CORNELIUS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280317744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048953415 | ||||||||
| FaxNumber: | 7048953416 | ||||||||
| Practice Location | |||||||||
| Address1: | 4920 ALBERMARLE RD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282056618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045682900 | ||||||||
| FaxNumber: | 7045680164 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | LE | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | TUAN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7045682900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5900375 | 05 | NC | MEDICAID |