Basic Information
| Provider Information | |||||||||
| NPI: | 1700965902 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAROLINA CLINIC FOR DIGESTIVE DISEASES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1040 X RAY DR | ||||||||
| Address2: | STE B | ||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280545438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048549990 | ||||||||
| FaxNumber: | 7048549045 | ||||||||
| Practice Location | |||||||||
| Address1: | 1040 X RAY DR | ||||||||
| Address2: | STE B | ||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280545438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048549990 | ||||||||
| FaxNumber: | 7048549045 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | CADDICK | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7048549990 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 33956 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 8902001 | 05 | NC | MEDICAID |