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	207QS0010X	Sports Medicine (Family Medicine) Physician
2	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1811517170
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	:	7482 WATERSIDE CROSSING BLVD
Second Line	:	STE 202
City	:	DENVER
State	:	NC
Zip	:	28037-3005
Country	:	US
Telephone Number	:	704-801-7320
Fax Number	:

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

Provider Enumeration Date	:	04/16/2020
Last Update Date	:	03/09/2023

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