Healthcare Provider Details

I. General information

NPI: 1083649214
Provider Name (Legal Business Name): CHARLOTTE MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 09/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 BLYTHE BLVD MCP SUITE 500
CHARLOTTE NC
28203-5874
US

IV. Provider business mailing address

PO BOX 601643
CHARLOTTE NC
28260-1643
US

V. Phone/Fax

Practice location:
  • Phone: 704-355-5100
  • Fax: 704-355-5180
Mailing address:
  • Phone: 704-355-5100
  • Fax: 704-342-4354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 8
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DANIEL L WIENS
Title or Position: SENIOR VICE PRESIDENT
Credential:
Phone: 704-355-0648