1821314618 NPI number — MECKLENBURG MEDICAL GROUP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821314618 NPI number — MECKLENBURG MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MECKLENBURG MEDICAL GROUP
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:
Provider Other Organization Name Type Code:
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:
1821314618
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/19/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 60063
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:
28260-0063
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-302-8800
Provider Business Mailing Address Fax Number:
704-632-4001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 SOUTH COLLEGE STREET
Provider Second Line Business Practice Location Address:
SUITE 500
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28202-2067
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-302-8800
Provider Business Practice Location Address Fax Number:
704-632-4001
Provider Enumeration Date:
04/19/2010

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 OPERATIONS
Authorized Official Telephone Number:
704-355-0648

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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