Basic Information
| Provider Information | |||||||||
| NPI: | 1679991301 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOSPICE & PALLIATIVE CARE CHARLOTTE REGION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | HOSPICE & PALLIATIVE CARE PALMETTO REGION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 470408 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282470408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043750100 | ||||||||
| FaxNumber: | 7048876450 | ||||||||
| Practice Location | |||||||||
| Address1: | 1057 RED VENTURES DR | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | FORT MILL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297075001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043750100 | ||||||||
| FaxNumber: | 7043758623 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2014 | ||||||||
| LastUpdateDate: | 09/13/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BRUNNICK | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 7043353501 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HOSPICE & PALLIATIVE CARE CHARLOTTE REGION | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | C.P.A | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 251G00000X | HPC-0047 | SC | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | H031 | 01 | SC | MEDICARE PART B | OTHER | 421626 | 01 | SC | MEDICARE | OTHER | HSP151 | 05 | SC | MEDICAID |