Healthcare Provider Details

I. General information

NPI: 1164466447
Provider Name (Legal Business Name): WESTERN CAROLINA CARDIOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 11/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32 PHYSICIAN DR
CLYDE NC
28721-8486
US

IV. Provider business mailing address

32 PHYSICIAN DR
CLYDE NC
28721-8486
US

V. Phone/Fax

Practice location:
  • Phone: 828-564-9222
  • Fax: 828-564-9228
Mailing address:
  • Phone: 828-564-9222
  • Fax: 828-564-9228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0050-02618
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number9801441
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number200000225
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number200200031
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number2009-01377
License Number StateNC

VIII. Authorized Official

Name: MR. DAVID W PETERSON
Title or Position: PARTNER
Credential: M.D.
Phone: 828-564-9222