MEDICARE: PAGELAND FAMILY MEDICINE

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	:	1992735989
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAGELAND FAMILY MEDICINE

Provider Business Mailing Address
First Line	:	5000 AIRPORT CENTER PKWY STE A
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28208-5899
Country	:	US
Telephone Number	:	704-512-4116
Fax Number	:	704-371-7284

Provider Business Practice Location Address
First Line	:	301 N VAN LINGLE MUNGO BLVD
Second Line	:
City	:	PAGELAND
State	:	SC
Zip	:	29728
Country	:	US
Telephone Number	:	843-672-6127
Fax Number	:	843-672-5748

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

Provider Enumeration Date	:	07/04/2006
Last Update Date	:	08/22/2020

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Directions to “PAGELAND FAMILY MEDICINE ” Practice Location

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