Basic Information
| Provider Information | |||||||||
| NPI: | 1619936952 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAROLINA CARDIOLOGY ASSOCIATES, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 306 WESTWOOD AVE | ||||||||
| Address2: | SUITE 401 | ||||||||
| City: | HIGH POINT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272624341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368856168 | ||||||||
| FaxNumber: | 3368850909 | ||||||||
| Practice Location | |||||||||
| Address1: | 306 WESTWOOD AVE | ||||||||
| Address2: | SUITE 401 | ||||||||
| City: | HIGH POINT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272624341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368856168 | ||||||||
| FaxNumber: | 3368850909 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2006 | ||||||||
| LastUpdateDate: | 09/04/2007 | ||||||||
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| AuthorizedOfficialLastName: | HODGE | ||||||||
| AuthorizedOfficialFirstName: | JIM | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTATOR | ||||||||
| AuthorizedOfficialTelephone: | 3368856168 | ||||||||
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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 | 207RC0000X | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 8901831 | 05 | NC | MEDICAID |