Basic Information
| Provider Information | |||||||||
| NPI: | 1457557795 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CMC-NORTHEAST, INC. | ||||||||
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| OtherOrganizationName: | CAROLINAS PEDIATRIC NEUROLOGY CARE - HUNTERSVILLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9625 NORTHCROSS CENTER CT | ||||||||
| Address2: | SUITE 102-B | ||||||||
| City: | HUNTERSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280787348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048011240 | ||||||||
| FaxNumber: | 7048011241 | ||||||||
| Practice Location | |||||||||
| Address1: | 9625 NORTHCROSS CENTER CT | ||||||||
| Address2: | SUITE 102-B | ||||||||
| City: | HUNTERSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280787348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048011240 | ||||||||
| FaxNumber: | 7048011241 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2007 | ||||||||
| LastUpdateDate: | 08/21/2012 | ||||||||
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| AuthorizedOfficialLastName: | LOWDER | ||||||||
| AuthorizedOfficialFirstName: | FRIEDA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | VP | ||||||||
| AuthorizedOfficialTelephone: | 7044034146 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CMC-NORTHEAST, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0402X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology |
ID Information
| ID | Type | State | Issuer | Description | 5906850 | 05 | NC | MEDICAID | NPB455 | 05 | SC | MEDICAID | DF8926 | 01 | NC | RAILROAD MEDICARE PTAN | OTHER | 015Y1 | 01 | NC | BCBS | OTHER | 019FG | 01 | NC | BCBS EFF 7-1-07 | OTHER | 5914183 | 05 | NC | MEDICAID | 355573 | 01 | NC | MAMSI | OTHER |