1093762627 NPI number — CMC - NORTHEAST, INC.

Table of content: (NPI 1093762627)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093762627 NPI number — CMC - NORTHEAST, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CMC - NORTHEAST, 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:
Provider Other Organization Name Type Code:
6
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:
1093762627
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
130 LAKE CONCORD RD NE
Provider Second Line Business Mailing Address:
SUITE B NE INTERNAL MEDICINE
Provider Business Mailing Address City Name:
CONCORD
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28025-1918
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-652-7270
Provider Business Mailing Address Fax Number:
704-788-1935

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
130 LAKE CONCORD RD NE
Provider Second Line Business Practice Location Address:
SUITE B NE INTERNAL MEDICINE
Provider Business Practice Location Address City Name:
CONCORD
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28025-1918
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-652-7270
Provider Business Practice Location Address Fax Number:
704-788-1935
Provider Enumeration Date:
05/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LOWDER
Authorized Official First Name:
FRIEDA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
VP PHYSICIAN SERVICES
Authorized Official Telephone Number:
704-783-4146

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)

  • Identifier: 355573 . This is a "MAMSI" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 566000156041 . This is a "TRICARE STANDARD, NON NWK" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: F158 . This is a "PARTNERS MEDICARE CHOICE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: CC2854 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 011XF . This is a "BCBS GROUP ID" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 89011XF , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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