Basic Information
| Provider Information | |||||||||
| NPI: | 1780913921 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHARLOTTE MEDICAL CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 601643 | ||||||||
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| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282601643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045124808 | ||||||||
| FaxNumber: | 7045124838 | ||||||||
| Practice Location | |||||||||
| Address1: | 10545 BLAIR ROAD | ||||||||
| Address2: | SUITE 2100 | ||||||||
| City: | MINT HILL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282272804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048639500 | ||||||||
| FaxNumber: | 7048639501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2009 | ||||||||
| LastUpdateDate: | 10/24/2012 | ||||||||
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| AuthorizedOfficialLastName: | WIENS | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7043550648 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5908921 | 05 | NC | MEDICAID |