Basic Information
| Provider Information | |||||||||
| NPI: | 1619371697 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CAROLINAS PHYSICIANS NETWORK, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LOCUST MEDICAL SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 601888 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282601888 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048880580 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 103 STANLY PKWY | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LOCUST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280977710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048880580 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2014 | ||||||||
| LastUpdateDate: | 08/12/2016 | ||||||||
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| AuthorizedOfficialLastName: | LAYMON | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | FORD | ||||||||
| AuthorizedOfficialTitleorPosition: | SVP | ||||||||
| AuthorizedOfficialTelephone: | 7046310002 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CAROLINAS PHYSICIANS NETWORK, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1619371697 | 05 | NC | MEDICAID |