Healthcare Provider Details

I. General information

NPI: 1639425796
Provider Name (Legal Business Name): CAROLINAS PHYSICIANS NETWORK INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2012
Last Update Date: 11/20/2025
Certification Date: 11/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3030 RANDOLPH RD STE 105
CHARLOTTE NC
28211-1368
US

IV. Provider business mailing address

PO BOX 19305
CHARLOTTE NC
28219-9305
US

V. Phone/Fax

Practice location:
  • Phone: 704-863-4878
  • Fax:
Mailing address:
  • Phone: 704-631-0002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: SCOTT RISSMILLER
Title or Position: PRESIDENT
Credential:
Phone: 704-631-0002