1376696062 NPI number — CMC-NORTHEAST, INC

Table of content: (NPI 1376696062)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376696062 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:
1376696062
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16623 BIRKDALE CMNS PKWY
Provider Second Line Business Mailing Address:
SUITE 110, NE PEDIATRIC ENDO
Provider Business Mailing Address City Name:
HUNTERSVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28078-5621
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-987-4277
Provider Business Mailing Address Fax Number:
704-987-5096

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16623 BIRKDALE CMNS PKWY
Provider Second Line Business Practice Location Address:
SUITE 110, NE PEDIATRIC ENDO
Provider Business Practice Location Address City Name:
HUNTERSVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28078-5621
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-987-4277
Provider Business Practice Location Address Fax Number:
704-987-5096
Provider Enumeration Date:
01/18/2007

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 COORD
Authorized Official Telephone Number:
704-783-4146

Provider Taxonomy Codes

  • Taxonomy code: 2080P0205X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: I902 . This is a "PARTNERS MEDICARE CHOICE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 355573 . This is a "MAMSI" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 5903854 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 566000156074 . This is a "TRICARE STANDARD, NON NWK" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 015Y2 . This is a "BCBS GROUP ID" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 4462028 . This is a "AETNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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