Basic Information
| Provider Information | |||||||||
| NPI: | 1548398720 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOSPICE & PALLIATIVE CARE CHARLOTTE REGION | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 470408 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282470408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043750100 | ||||||||
| FaxNumber: | 7048876450 | ||||||||
| Practice Location | |||||||||
| Address1: | 7845 LITTLE AVE | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282268198 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043750100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2007 | ||||||||
| LastUpdateDate: | 05/03/2018 | ||||||||
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| AuthorizedOfficialLastName: | BRUNNICK | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
| AuthorizedOfficialMiddleName: | ALLEN | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7043750100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CPA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 251G00000X | HC0369 | NC | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | HSP034 | 05 | SC | MEDICAID | 3401500 | 05 | NC | MEDICAID | 89015M4 | 05 | NC | MEDICAID |