Basic Information
| Provider Information | |||||||||
| NPI: | 1821246760 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CAROLINAS PHYSICIANS NETWORK INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CAROLINA CANCER SPECIALISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 602148 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282602148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8033299088 | ||||||||
| FaxNumber: | 8033299075 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 S HERLONG AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | ROCK HILL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297322168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8033299088 | ||||||||
| FaxNumber: | 8033299075 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2008 | ||||||||
| LastUpdateDate: | 07/05/2013 | ||||||||
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| AuthorizedOfficialLastName: | WIENS | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7043550648 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CAROLINAS PHYSICIANS NETWORK INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 5950534 | 05 | NC | MEDICAID | GP4985 | 05 | SC | MEDICAID |