Basic Information
| Provider Information | |||||||||
| NPI: | 1588700751 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE CHARLOTTE-MECKLENBURG HOSPITAL AUTHORITY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PEDIATRIC HEMATOLOGY ONCOLOGY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 32861 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282322861 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045126438 | ||||||||
| FaxNumber: | 7045126485 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 BLYTHE BLVD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282035812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043552000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2007 | ||||||||
| LastUpdateDate: | 04/19/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | GOMBAR | ||||||||
| AuthorizedOfficialFirstName: | GREG | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7043552154 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | NPA501 | 05 | SC | MEDICAID | 590123E | 05 | NC | MEDICAID |