1437484243 NPI number — CAROLINAS PHYSICIANS NETWORK, INC.

Table of content: JESSICA LAUREN RICHARDSON RD (NPI 1003550815)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437484243 NPI number — CAROLINAS PHYSICIANS NETWORK, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAROLINAS 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:
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:
1437484243
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/11/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 602478
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:
28260-2478
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-377-9323
Provider Business Mailing Address Fax Number:
704-331-4030

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10320 MALLARD CREEK ROAD
Provider Second Line Business Practice Location Address:
SUITE 230
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28262-5209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-377-9323
Provider Business Practice Location Address Fax Number:
704-331-4030
Provider Enumeration Date:
10/13/2009

Additional Information

Authorized Official

Authorized Official Last Name:
LAYMON
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
FORD
Authorized Official Title or Position:
SENIOR VICE PRESIDENT
Authorized Official Telephone Number:
704-631-0002

Provider Taxonomy Codes

  • Taxonomy code: 2084N0402X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084N0600X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084N0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: NPB338 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5913179 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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