Healthcare Provider Details

I. General information

NPI: 1477484863
Provider Name (Legal Business Name): MID CAROLINA PSYCHIATRY, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2026
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 N CHURCH ST UNIT 1015
CHARLOTTE NC
28202-2264
US

IV. Provider business mailing address

210 N CHURCH ST UNIT 1015
CHARLOTTE NC
28202-2264
US

V. Phone/Fax

Practice location:
  • Phone: 704-209-9470
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: KEITH LOGAN
Title or Position: OWNER
Credential: MD
Phone: 704-209-9470