Basic Information
| Provider Information | |||||||||
| NPI: | 1730149436 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLEVELAND COUNTY HEALTHCARE SYSTEM | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 601409 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282601409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7044801087 | ||||||||
| FaxNumber: | 7044843260 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 E GROVER ST | ||||||||
| Address2: | |||||||||
| City: | SHELBY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281503917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8005130025 | ||||||||
| FaxNumber: | 9194775474 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2006 | ||||||||
| LastUpdateDate: | 02/08/2010 | ||||||||
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| AuthorizedOfficialLastName: | GUNTER | ||||||||
| AuthorizedOfficialFirstName: | WENDY | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING/CODING DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7044801087 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 0762X | 01 | NC | BLUE CROSS BLUE SHIELD | OTHER | 8907694 | 05 | NC | MEDICAID |