Basic Information
| Provider Information | |||||||||
| NPI: | 1528085313 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORTHOCAROLINA | ||||||||
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| OtherOrganizationName: | KINGS MOUNTAIN | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4601 PARK RD | ||||||||
| Address2: | STE 300 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282093239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043232256 | ||||||||
| FaxNumber: | 7043233911 | ||||||||
| Practice Location | |||||||||
| Address1: | 502 W KING ST | ||||||||
| Address2: | SUITE 100-C | ||||||||
| City: | KINGS MOUNTAIN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280863362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7047390277 | ||||||||
| FaxNumber: | 7043391444 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | LAYMON | ||||||||
| AuthorizedOfficialFirstName: | TOM | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7043391000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 363A00000X | X | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 8901619 | 05 | NC | MEDICAID |