Basic Information
| Provider Information | |||||||||
| NPI: | 1528118569 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCEWEN | ||||||||
| FirstName: | MARIANNE | ||||||||
| MiddleName: | J.R. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60447 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282600447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043849679 | ||||||||
| FaxNumber: | 7043160508 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 HAWTHORNE LN | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282042515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043847508 | ||||||||
| FaxNumber: | 7043848666 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2007 | ||||||||
| LastUpdateDate: | 02/20/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 200700892 | NC | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0203X | 200700892 | NC | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine | 2080P0203X | 036104630 | IL | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036104630 | 05 | IL | MEDICAID | 5908437 | 05 | NC | MEDICAID |