Basic Information
Provider Information | |||||||||
NPI: | 1922367077 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CAROLINAS MEDICAL CENTER-NORTHEAST | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CAROLINAS PEDIATRIC NEUROLOGY CARE-MORROCROFT | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4501 CAMERON VALLEY PKWY | ||||||||
Address2: | SUITE 301-A | ||||||||
City: | CHARLOTTE | ||||||||
State: | NC | ||||||||
PostalCode: | 282114297 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7044032660 | ||||||||
FaxNumber: | 7044032670 | ||||||||
Practice Location | |||||||||
Address1: | 4501 CAMERON VALLEY PKWY | ||||||||
Address2: | SUITE 301-A | ||||||||
City: | CHARLOTTE | ||||||||
State: | NC | ||||||||
PostalCode: | 282114297 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7044032660 | ||||||||
FaxNumber: | 7044032670 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/10/2012 | ||||||||
LastUpdateDate: | 09/05/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LOWDER | ||||||||
AuthorizedOfficialFirstName: | FRIEDA | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | SR. VICE PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 7044034146 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | CAROLINAS MEDICAL CENTER-NORTHEAST | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0402X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology |
ID Information
ID | Type | State | Issuer | Description | 5920684 | 05 | NC |   | MEDICAID |