Basic Information
| Provider Information | |||||||||
| NPI: | 1487945945 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUICE | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | AARON | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 S KINGS DR | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282071808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708947002 | ||||||||
| FaxNumber: | 7043816841 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 BLYTHE BLVD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282035812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043816806 | ||||||||
| FaxNumber: | 7043816841 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2011 | ||||||||
| LastUpdateDate: | 12/11/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 173240 | NC | N | Allopathic & Osteopathic Physicians | Pediatrics | 207P00000X | MD.33337 | AL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 208000000X | MD.33337 | AL | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 160753 | 05 | AL | MEDICAID | 511-49844 | 01 | AL | BCBS | OTHER | 160757 | 05 | AL | MEDICAID | 511-49842 | 01 | AL | BCBS | OTHER |