Basic Information
| Provider Information | |||||||||
| NPI: | 1417570771 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HOSPICE & PALLIATIVE CARE CHARLOTTE REGION | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 470408 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282470408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043750100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1057 RED VENTURES DR STE 150 | ||||||||
| Address2: | |||||||||
| City: | FORT MILL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297072518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8035483708 | ||||||||
| FaxNumber: | 8034312249 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2020 | ||||||||
| LastUpdateDate: | 05/21/2020 | ||||||||
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| AuthorizedOfficialLastName: | BRUNNICK | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/ CEO | ||||||||
| AuthorizedOfficialTelephone: | 7043353501 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QH0002X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Hospice and Palliative Medicine |
ID Information
| ID | Type | State | Issuer | Description | GP8345 | 05 | SC | MEDICAID |