Healthcare Provider Details

I. General information

NPI: 1437438694
Provider Name (Legal Business Name): CAROLINA MEDICORP ENTERPRISES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2011
Last Update Date: 11/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1918 RANDOLPH RD SUITE 175
CHARLOTTE NC
28207-1107
US

IV. Provider business mailing address

PO BOX 751803
CHARLOTTE NC
28275-1803
US

V. Phone/Fax

Practice location:
  • Phone: 704-316-1050
  • Fax: 704-316-1051
Mailing address:
  • Phone: 704-316-1050
  • Fax: 704-316-1051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. GEOFFREY GARDNER
Title or Position: VP FINANCE
Credential:
Phone: 70438499490