Basic Information
| Provider Information | |||||||||
| NPI: | 1477995082 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAROLINAS PHYSICIANS NETWORK, INC. | ||||||||
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| OtherOrganizationName: | CLEVELAND PLASTIC AND HAND SURGERY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 601884 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282601884 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9804872340 | ||||||||
| FaxNumber: | 9804872341 | ||||||||
| Practice Location | |||||||||
| Address1: | 823 E KING ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | KINGS MOUNTAIN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280863186 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9804872340 | ||||||||
| FaxNumber: | 9804872341 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2013 | ||||||||
| LastUpdateDate: | 01/07/2014 | ||||||||
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| AuthorizedOfficialLastName: | WIENS | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | SVP/OPERATIONS CPN | ||||||||
| AuthorizedOfficialTelephone: | 7043550648 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CAROLINAS PHYSICIANS NETWORK, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery | 2082S0105X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery | Surgery of the Hand |
ID Information
| ID | Type | State | Issuer | Description | NPB563 | 05 | SC | MEDICAID | 1477995082 | 05 | NC | MEDICAID |