Healthcare Provider Details

I. General information

NPI: 1922537612
Provider Name (Legal Business Name): CAROLINA MEDICORP ENTERPRISES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2017
Last Update Date: 11/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11840 SOUTHMORE DR STE 100
CHARLOTTE NC
28277-4821
US

IV. Provider business mailing address

PO BOX 751803
CHARLOTTE NC
28275-1803
US

V. Phone/Fax

Practice location:
  • Phone: 704-316-4440
  • Fax:
Mailing address:
  • Phone: 704-316-4440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GEOFFREY KEITH GARDNER
Title or Position: VP FINANCE
Credential:
Phone: 704-384-7603