1477508836 NPI number — THE CAROLINAS EMERGENCY GROUP, PLLC

Table of content: (NPI 1477508836)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477508836 NPI number — THE CAROLINAS EMERGENCY GROUP, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE CAROLINAS EMERGENCY GROUP, PLLC
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:
1477508836
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/16/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 21333
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELFAST
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04915-4110
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-874-5400
Provider Business Mailing Address Fax Number:
770-874-5483

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 TILGHMAN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DUNN
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28334-5510
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-892-7161
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LARSEN
Authorized Official First Name:
KIM
Authorized Official Middle Name:
H
Authorized Official Title or Position:
DIRECTOR OF CREDENTIALING
Authorized Official Telephone Number:
770-874-5400

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5902730 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 017PA . This is a "BLUE CROSS GROUP NUMBER" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 012949100 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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