Healthcare Provider Details

I. General information

NPI: 1083905079
Provider Name (Legal Business Name): CAROLINAS MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2011
Last Update Date: 04/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14214 BALLANTYNE LAKE RD SUITE 150
CHARLOTTE NC
28277-3372
US

IV. Provider business mailing address

PO BOX 601372
CHARLOTTE NC
28260-1372
US

V. Phone/Fax

Practice location:
  • Phone: 704-667-2680
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. DENNIE UNDERWOOD
Title or Position: VICE PRESIDENT
Credential:
Phone: 704-355-3147