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

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	:	1215125919
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAROLINAS PHYSICIANS NETWORK INC.

Provider Business Mailing Address
First Line	:	PO BOX 601949
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28260-1949
Country	:	US
Telephone Number	:	704-545-4609
Fax Number	:	704-545-4798

Provider Business Practice Location Address
First Line	:	4105 MATTHEWS MINT HILL RD
Second Line	:
City	:	MATTHEWS
State	:	NC
Zip	:	28105-3633
Country	:	US
Telephone Number	:	704-545-4609
Fax Number	:	704-545-4798

Authorized Official
Title or Position	:	SENIOR VICE PRESIDENT OF OPERATIONS
Name	:	MR. DANIEL L. WIENS
Credential	:
Telephone Number	:	704-355-0648

Provider Enumeration Date	:	10/09/2007
Last Update Date	:	12/22/2010

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