Basic Information
Provider Information | |||||||||
NPI: | 1407299795 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CAROLINAS MEDICAL CENTER-NORTHEAST | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | NORTHEAST RHEUMATOLOGY-UNIVERSITY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 101 E WT HARRIS BLVD | ||||||||
Address2: | BLDG 3000, SUITE 3301-G | ||||||||
City: | CHARLOTTE | ||||||||
State: | NC | ||||||||
PostalCode: | 282627000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7044031308 | ||||||||
FaxNumber: | 7044031194 | ||||||||
Practice Location | |||||||||
Address1: | 101 E WT HARRIS BLVD | ||||||||
Address2: | BLDG 3000, SUITE 3301-G | ||||||||
City: | CHARLOTTE | ||||||||
State: | NC | ||||||||
PostalCode: | 282627000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7044031308 | ||||||||
FaxNumber: | 7044031194 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/17/2013 | ||||||||
LastUpdateDate: | 04/17/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LOWDER | ||||||||
AuthorizedOfficialFirstName: | FRIEDA | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | SR. VICE PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 7044034146 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | CAROLINAS MEDICAL CENTER-NORTHEAST | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RR0500X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology |
No ID Information.