Basic Information
| Provider Information | |||||||||
| NPI: | 1518237825 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAROLINAS MEDICAL CENTER-NORTHEAST | ||||||||
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| OtherOrganizationName: | NORTHEAST DERMATOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 MEDICAL PARK DRIVE | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280250936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7044032777 | ||||||||
| FaxNumber: | 7044032779 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 MEDICAL PARK DRIVE | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280250936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7044032777 | ||||||||
| FaxNumber: | 7044032779 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2012 | ||||||||
| LastUpdateDate: | 03/28/2012 | ||||||||
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| AuthorizedOfficialLastName: | LOWDER | ||||||||
| AuthorizedOfficialFirstName: | FRIEDA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | SR. VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7044034146 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CAROLINAS MEDICAL CENTER-NORTHEAST | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 232009 | 01 | NC | MEDICARE PTAN, GROUP | OTHER | 5919313 | 05 | NC | MEDICAID | DF8926 | 01 | NC | RAILROAD MEDICARE PTAN, GROUP | OTHER |