Healthcare Provider Details

I. General information

NPI: 1508364886
Provider Name (Legal Business Name): CARDIAC CIN OF CHARLOTTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2018
Last Update Date: 02/13/2020
Certification Date: 02/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15720 BRIXHAM HILL AVE STE 300C
CHARLOTTE NC
28277-4784
US

IV. Provider business mailing address

102 WOODMONT BLVD STE 350
NASHVILLE TN
37205-2216
US

V. Phone/Fax

Practice location:
  • Phone: 615-386-0064
  • Fax: 615-386-0067
Mailing address:
  • Phone: 615-386-0064
  • Fax: 615-386-0067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number StateNC

VIII. Authorized Official

Name: EDWARD LELAND HUTTON EADIE
Title or Position: DIRECTOR
Credential:
Phone: 615-733-2064