Healthcare Provider Details

I. General information

NPI: 1346589520
Provider Name (Legal Business Name): CAROLINAS PHYSICIAN NETWORK, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2013
Last Update Date: 08/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E W T HARRIS BLVD SUITE 5101
CHARLOTTE NC
28262-3485
US

IV. Provider business mailing address

PO BOX 602148
CHARLOTTE NC
28260-2148
US

V. Phone/Fax

Practice location:
  • Phone: 704-863-4878
  • Fax: 704-863-1511
Mailing address:
  • Phone: 704-863-4878
  • Fax: 704-863-1511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. THOMAS FORD LAYMON
Title or Position: SENIOR VICE PRESIDENT
Credential:
Phone: 704-631-0002