Healthcare Provider Details

I. General information

NPI: 1407032055
Provider Name (Legal Business Name): PIEDMONT SURGICAL CLINIC, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2008
Last Update Date: 11/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

431 COPPERFIELD BLVD NE
CONCORD NC
28025-3035
US

IV. Provider business mailing address

431 COPPERFIELD BLVD NE
CONCORD NC
28025-2405
US

V. Phone/Fax

Practice location:
  • Phone: 704-786-1104
  • Fax: 704-788-3112
Mailing address:
  • Phone: 704-786-1104
  • Fax: 704-788-3112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. TAMMY S MILLER
Title or Position: OFFICE MANAGER
Credential:
Phone: 704-786-1104