Basic Information
| Provider Information | |||||||||
| NPI: | 1609944024 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAROLINA MEDICAL SPECIALTIES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 53277 | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283053277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104850500 | ||||||||
| FaxNumber: | 9104852600 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 1/2 BRAGG BLVD | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283014513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104850500 | ||||||||
| FaxNumber: | 9104852060 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2006 | ||||||||
| LastUpdateDate: | 01/18/2008 | ||||||||
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| AuthorizedOfficialLastName: | SLEEM | ||||||||
| AuthorizedOfficialFirstName: | DIMITRI | ||||||||
| AuthorizedOfficialMiddleName: | K. | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9104850500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | 01069 | NC | N | Suppliers | Durable Medical Equipment & Medical Supplies | 335E00000X | 01069 | NC | N | Suppliers | Prosthetic/Orthotic Supplier | 332BC3200X | 01069 | NC | Y | Suppliers | Durable Medical Equipment & Medical Supplies | Customized Equipment |
ID Information
| ID | Type | State | Issuer | Description | 7704467 | 05 | NC | MEDICAID |