1790779254 NPI number — DR. BRENT BLAIR WARREN MD

Table of content: CADEN WALLACE BERGANTINO (NPI 1912704784)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790779254 NPI number — DR. BRENT BLAIR WARREN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WARREN
Provider First Name:
BRENT
Provider Middle Name:
BLAIR
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1790779254
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/26/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6035 FAIRVIEW RD
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:
28210-3256
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-295-3000
Provider Business Mailing Address Fax Number:
704-838-8494

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
646 HARTNESS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STATESVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28677-3423
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-872-4108
Provider Business Practice Location Address Fax Number:
704-873-6517
Provider Enumeration Date:
09/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  200301426 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2407151 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 136WP . This is a "BCBSNC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 000000295044 . This is a "UNISON HEALTH PLAN SC" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 188941 . This is a "MEDCOST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 7833504 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00292839 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: G0142B , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 81900 . This is a "CHCARES OF SC" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 20096157 . This is a "SELECT HEALTH OF SC" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 89136WP , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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