Basic Information
| Provider Information | |||||||||
| NPI: | 1710979026 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LARSEN | ||||||||
| FirstName: | LARS | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 751069 | ||||||||
| Address2: | ECU PHYSICIANS FAMILY MEDICINE | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282751069 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 101 HEART DRIVE | ||||||||
| Address2: | ECU PHYSICIANS FAMILY MEDICINE | ||||||||
| City: | GREENVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278348944 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2527444611 | ||||||||
| FaxNumber: | 2527442056 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2005 | ||||||||
| LastUpdateDate: | 10/26/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 27479 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 80106314 | 01 | NC | RAILROAD MEDICARE | OTHER | 51050 | 01 | NC | BCBS NC | OTHER | 7951050 | 05 | NC | MEDICAID |