MEDICARE: CAROLINA PSYCHIATRIC ASSOCIATES, PA

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	2084P0800X	Psychiatry Physician	9800612	NC

General Provider Information

NPI Number	:	1114213998
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAROLINA PSYCHIATRIC ASSOCIATES, PA

Provider Business Mailing Address
First Line	:	2701 COLTSGATE RD
Second Line	:	SUITE 105
City	:	CHARLOTTE
State	:	NC
Zip	:	28211-3534
Country	:	US
Telephone Number	:	704-541-1213
Fax Number	:	704-541-4210

Provider Business Practice Location Address
First Line	:	2701 COLTSGATE RD
Second Line	:	SUITE 105
City	:	CHARLOTTE
State	:	NC
Zip	:	28211-3534
Country	:	US
Telephone Number	:	704-541-1213
Fax Number	:	704-541-4210

Authorized Official
Title or Position	:	OWNER/PROVIDER
Name	:	KEITH LOGAN
Credential	:	M.D.
Telephone Number	:	704-541-1213

Provider Enumeration Date	:	06/21/2011
Last Update Date	:	09/08/2011

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