Healthcare Provider Details

I. General information

NPI: 1982075388
Provider Name (Legal Business Name): OBSERVATION MEDICINE PHYSICIANS OF MECKLENBURG COUNTY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2015
Last Update Date: 07/18/2023
Certification Date: 07/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8800 N TRYON ST
CHARLOTTE NC
28262-3300
US

IV. Provider business mailing address

4535 DRESSLER RD NW
CANTON OH
44718-2545
US

V. Phone/Fax

Practice location:
  • Phone: 330-493-4443
  • Fax: 330-451-4197
Mailing address:
  • Phone: 330-493-4443
  • Fax: 330-493-8677

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 Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ANDREW WAGNER
Title or Position: MD
Credential: MD
Phone: 330-493-4443