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:  
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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:  
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AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
2084N0402X  Y193400000X SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology

ID Information
IDTypeStateIssuerDescription
592068405NC MEDICAID


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