1578572939 NPI number — UNION PHYSICIANS NETWORK INC

Table of content: (NPI 1578572939)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578572939 NPI number — UNION PHYSICIANS NETWORK INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UNION PHYSICIANS NETWORK INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LAKE PARK FAMILY PRACTICE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578572939
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/28/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 60643
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28260-0643
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-882-1666
Provider Business Mailing Address Fax Number:
704-882-2789

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6208 CREFT CIR
Provider Second Line Business Practice Location Address:
SUITE 222
Provider Business Practice Location Address City Name:
INDIAN TRAIL
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28079-9003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-882-1666
Provider Business Practice Location Address Fax Number:
704-882-2789
Provider Enumeration Date:
08/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WIENS
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
L
Authorized Official Title or Position:
SENIOR VICE PRESIDENT
Authorized Official Telephone Number:
704-355-0648

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7705363 . This is a "NC MEDICAID DME SUPPLIER" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 014PK . This is a "BLUE CROSS - BLUE SHIELD" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 89014PK , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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