Healthcare Provider Details

I. General information

NPI: 1245338557
Provider Name (Legal Business Name): CAROLINA SURGICAL CLINIC OF CHARLOTTE, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2104 RANDOLPH RD
CHARLOTTE NC
28207-1522
US

IV. Provider business mailing address

2104 RANDOLPH RD
CHARLOTTE NC
28207-1522
US

V. Phone/Fax

Practice location:
  • Phone: 704-377-3900
  • Fax: 704-377-1244
Mailing address:
  • Phone: 704-377-3900
  • Fax: 704-377-1244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. JACQUE HOVIS GREENWAY
Title or Position: CLINIC MANAGER
Credential:
Phone: 704-377-3900