MEDICARE: MECKLENBURG MEDICAL GROUP

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	207N00000X	Dermatology Physician
2	207RC0000X	Cardiovascular Disease Physician
3	207RE0101X	Endocrinology, Diabetes & Metabolism Physician
4	207RG0100X	Gastroenterology Physician
5	207RH0003X	Hematology & Oncology Physician
6	207RI0200X	Infectious Disease Physician
7	207RP1001X	Pulmonary Disease Physician
8	207RR0500X	Rheumatology Physician
9	207R00000X	Internal 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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
9	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
10	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
11	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
12	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255364535
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MECKLENBURG MEDICAL GROUP

Provider Business Mailing Address
First Line	:	PO BOX 601643
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28260-1643
Country	:	US
Telephone Number	:	704-367-8610
Fax Number	:	704-367-6798

Provider Business Practice Location Address
First Line	:	7903 PROVIDENCE RD
Second Line	:	SUITE 100
City	:	CHARLOTTE
State	:	NC
Zip	:	28277-9720
Country	:	US
Telephone Number	:	704-367-8610
Fax Number	:	704-367-6798

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

Provider Enumeration Date	:	07/09/2006
Last Update Date	:	03/06/2013

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Directions to “MECKLENBURG MEDICAL GROUP ” Practice Location

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