Basic Information
| Provider Information | |||||||||
| NPI: | 1679512677 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CMC-NORTHEAST, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CAROLINA PEDIATRIC SURGERY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 MEDICAL PARK DR | ||||||||
| Address2: | SUITE 310 -CAROLINA PEDIATRIC SURGERY | ||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280252966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7044032660 | ||||||||
| FaxNumber: | 7044032670 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 MEDICAL PARK DR | ||||||||
| Address2: | SUITE 310 -CAROLINA PEDIATRIC SURGERY | ||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280252966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7044032660 | ||||||||
| FaxNumber: | 7044032670 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2006 | ||||||||
| LastUpdateDate: | 11/15/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LOWDER | ||||||||
| AuthorizedOfficialFirstName: | FRIEDA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | VP PHYSICIAN SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 7044034146 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CMC-NORTHEAST, INC. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0120X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Pediatric Surgery |
ID Information
| ID | Type | State | Issuer | Description | 355573 | 01 | NC | MAMSI | OTHER | 019FN | 01 | NC | BCBS EFF 7-1-07 | OTHER | QPB706 | 05 | SC | MEDICAID | DF8926 | 01 | NC | RAILROAD MEDICARE PTAN | OTHER | 241255803 | 01 | NC | TRICARE | OTHER | 5901473 | 05 | NC | MEDICAID | 5906961 | 05 | NC | MEDICAID | 017CP | 01 | NC | BCBS EFF PRIOR TO 7-1-07 | OTHER | 7878267 | 01 | NC | AETNA | OTHER |