Basic Information
| Provider Information | |||||||||
| NPI: | 1548509805 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAROLINAS PHYSICIAN NETWORK, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SPORTS MEDICINE AND INJURY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 602148 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282602148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048634878 | ||||||||
| FaxNumber: | 7045126891 | ||||||||
| Practice Location | |||||||||
| Address1: | 332 NORTH TRADE STREET | ||||||||
| Address2: | SUITE 1200 | ||||||||
| City: | MATTHEWS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281056566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048634878 | ||||||||
| FaxNumber: | 7045126891 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2013 | ||||||||
| LastUpdateDate: | 08/18/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LAYMON | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | FORD | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7046310002 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CAROLINAS PHYSICIAN NETWORK INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 207RS0010X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | NPB621 | 05 | SC | MEDICAID | 5922356 | 05 | NC | MEDICAID |