1255364535 NPI number — MECKLENBURG MEDICAL GROUP

Table of content: (NPI 1255364535)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255364535 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:
1255364535
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/06/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 601643
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:
28260-1643
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-367-8610
Provider Business Mailing Address Fax Number:
704-367-6798

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7903 PROVIDENCE RD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28277-9720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-367-8610
Provider Business Practice Location Address Fax Number:
704-367-6798
Provider Enumeration Date:
07/09/2006

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: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RE0101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RH0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RR0500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: E08621 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5902311 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 89013CO , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 89013CW , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 89013CY , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5903117 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 89013AF , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5901377 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5905557 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 89015NA , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 89013PP , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 89013CX , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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