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	2080S0010X	Pediatric Sports Medicine Physician
2	208000000X	Pediatrics Physician

General Provider Information

NPI Number	:	1538415906
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAROLINAS PHYSICIANS NETWORK INC

Provider Business Mailing Address
First Line	:	PO BOX 19305
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28219-9305
Country	:	US
Telephone Number	:	704-631-0002
Fax Number	:

Provider Business Practice Location Address
First Line	:	3173 W HIGHWAY 74
Second Line	:
City	:	MONROE
State	:	NC
Zip	:	28110-8437
Country	:	US
Telephone Number	:	704-283-2000
Fax Number	:

Authorized Official
Title or Position	:	ENTERPRISE EVP
Name	:	SCOTT RISSMILLER
Credential	:
Telephone Number	:	704-355-8675

Provider Enumeration Date	:	08/03/2012
Last Update Date	:	10/02/2025

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