Basic Information
| Provider Information | |||||||||
| NPI: | 1447231519 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VERMEULEN | ||||||||
| FirstName: | FRED | ||||||||
| MiddleName: | DONALD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1420 E SEVENTH ST | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282042408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043750100 | ||||||||
| FaxNumber: | 7043758623 | ||||||||
| Practice Location | |||||||||
| Address1: | 1420 E SEVENTH ST | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282042408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043750100 | ||||||||
| FaxNumber: | 7043758623 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2005 | ||||||||
| LastUpdateDate: | 09/02/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 26065 | NC | N | Other Service Providers | Specialist | 207QH0002X | 26065 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine | Hospice and Palliative Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8984992 | 05 | NC | MEDICAID |