MEDICARE: CAROLINAS PHYSICIANS NETWORK INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician
2	261QR1300X	Rural Health Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	42-3846	OTHER	SC	RURAL HEALTH CLINIC

General Provider Information

NPI Number	:	1073842290
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAROLINAS PHYSICIANS NETWORK INC

Provider Business Mailing Address
First Line	:	PO BOX 601888
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28260-1888
Country	:	US
Telephone Number	:	843-672-6127
Fax Number	:	843-672-5748

Provider Business Practice Location Address
First Line	:	301 NORTH VAN LINGLE MUNGO BLVD.
Second Line	:
City	:	PAGELAND
State	:	SC
Zip	:	29728-2319
Country	:	US
Telephone Number	:	843-672-6127
Fax Number	:	843-672-5748

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. DANIEL L WIENS
Credential	:
Telephone Number	:	704-355-0648

Provider Enumeration Date	:	12/17/2009
Last Update Date	:	03/25/2015

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