Basic Information
| Provider Information | |||||||||
| NPI: | 1629272646 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAROLINAS MEDICAL CENTER-UNIVERSITY | ||||||||
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| OtherOrganizationName: | UNIVERSITY INDEPENDENT PHYSICIANS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 601372 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282601372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045127562 | ||||||||
| FaxNumber: | 7045124808 | ||||||||
| Practice Location | |||||||||
| Address1: | 8800 N TRYON ST | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282623300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045127562 | ||||||||
| FaxNumber: | 7045124808 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2007 | ||||||||
| LastUpdateDate: | 08/12/2016 | ||||||||
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| AuthorizedOfficialLastName: | LAYMON | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | FORD | ||||||||
| AuthorizedOfficialTitleorPosition: | SVP | ||||||||
| AuthorizedOfficialTelephone: | 7046310002 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CAROLINAS MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 207V00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | NPB078 | 05 | SC | MEDICAID | 89015K5 | 05 | NC | MEDICAID |