MEDICARE: CAROLINAS MEDICAL ALLIANCE 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	208D00000X	General Practice Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1134186455
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAROLINAS MEDICAL ALLIANCE INC

Provider Business Mailing Address
First Line	:	101 JOHN ST
Second Line	:
City	:	LAKE CITY
State	:	SC
Zip	:	29560-2411
Country	:	US
Telephone Number	:	843-394-2031
Fax Number	:

Provider Business Practice Location Address
First Line	:	101 JOHN ST
Second Line	:
City	:	LAKE CITY
State	:	SC
Zip	:	29560-2411
Country	:	US
Telephone Number	:	843-394-2031
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF PROVIDER ENROLLMENT
Name	:	DEBBIE BREWER
Credential	:
Telephone Number	:	615-465-7000

Provider Enumeration Date	:	04/28/2006
Last Update Date	:	10/29/2007

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Directions to “CAROLINAS MEDICAL ALLIANCE INC ” Practice Location

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