Basic Information
| Provider Information | |||||||||
| NPI: | 1750517108 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CAROLINAS MEDICAL CENTER AT HOME LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | ATRIUM HEALTH AT HOME INFUSION AND EQUIPMENT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 602262 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282602262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045125333 | ||||||||
| FaxNumber: | 7045618580 | ||||||||
| Practice Location | |||||||||
| Address1: | 1701 ABBEY PL | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282093733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045125333 | ||||||||
| FaxNumber: | 7045618580 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2009 | ||||||||
| LastUpdateDate: | 04/01/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STOLZEBACH | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | ANTHONY | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7045122312 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336M0002X | N | Suppliers | Pharmacy | Mail Order Pharmacy | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 332BP3500X | N | Suppliers | Durable Medical Equipment & Medical Supplies | Parenteral & Enteral Nutrition | 333600000X | N | Suppliers | Pharmacy | 3336H0001X | 10319 | NC | Y | Suppliers | Pharmacy | Home Infusion Therapy Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2120921 | 01 | PK | OTHER | 0602453 | 05 | NC | MEDICAID |