Healthcare Provider Details

I. General information

NPI: 1831155738
Provider Name (Legal Business Name): CHARLOTTE COLON & RECTAL SURGERY ASSOCIATES PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 06/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2015 RANDOLPH RD SUITE 201
CHARLOTTE NC
28207-1200
US

IV. Provider business mailing address

2015 RANDOLPH RD SUITE 201
CHARLOTTE NC
28207-1200
US

V. Phone/Fax

Practice location:
  • Phone: 704-333-1259
  • Fax: 704-333-0371
Mailing address:
  • Phone: 704-333-1259
  • Fax: 704-333-0371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number40475
License Number StateNC

VIII. Authorized Official

Name: DR. WILLIAM ALFRED WALKER
Title or Position: PRESIDENT
Credential: M.D.
Phone: 704-333-1259