Healthcare Provider Details

I. General information

NPI: 1356880801
Provider Name (Legal Business Name): CAROLINAS PHYSICIANS NETWORK INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2017
Last Update Date: 03/13/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 MOREHEAD MEDICAL DR STE 275
CHARLOTTE NC
28204-2963
US

IV. Provider business mailing address

PO BOX 19305
CHARLOTTE NC
28219-9305
US

V. Phone/Fax

Practice location:
  • Phone: 704-446-5070
  • Fax:
Mailing address:
  • Phone: 704-631-0002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number
License Number State

VIII. Authorized Official

Name: SCOTT RISSMILLER
Title or Position: ENTERPRISE EVP
Credential:
Phone: 704-355-8675