Basic Information
| Provider Information | |||||||||
| NPI: | 1790747756 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ZIMMER | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60447 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282600447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043841440 | ||||||||
| FaxNumber: | 7043841452 | ||||||||
| Practice Location | |||||||||
| Address1: | 216 MOORE RD | ||||||||
| Address2: | |||||||||
| City: | KING | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270218703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3369834346 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2006 | ||||||||
| LastUpdateDate: | 03/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 32918 | NC | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 8989942 | 05 | NC | MEDICAID | N32918 | 05 | SC | MEDICAID |