Basic Information
| Provider Information | |||||||||
| NPI: | 1730279787 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CAROLINAS PHYSICIANS NETWORK INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CHARLOTTE CARDIOLOGY ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60309 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282600309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049441135 | ||||||||
| FaxNumber: | 7049441155 | ||||||||
| Practice Location | |||||||||
| Address1: | 309 S SHARON AMITY RD | ||||||||
| Address2: | STE. 200 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282112978 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049441135 | ||||||||
| FaxNumber: | 7049441155 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2006 | ||||||||
| LastUpdateDate: | 03/11/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WIENS | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 7043550648 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CAROLINAS PHYSICIANS NETWORK INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
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 | 019K0 | 01 | NC | BCBS | OTHER | 5907960 | 05 | NC | MEDICAID | 5907962 | 05 | NC | MEDICAID | QPB818 | 05 | SC | MEDICAID | 5907963 | 05 | NC | MEDICAID | NPB247 | 05 | SC | MEDICAID | GP4737 | 05 | SC | MEDICAID | NPB245 | 05 | SC | MEDICAID | 5907958 | 05 | NC | MEDICAID | 5907961 | 05 | NC | MEDICAID | 5907964 | 05 | NC | MEDICAID | NPB246 | 05 | SC | MEDICAID | 5907959 | 05 | NC | MEDICAID | NPB248 | 05 | SC | MEDICAID | QPB819 | 05 | SC | MEDICAID |