Healthcare Provider Details

I. General information

NPI: 1700101128
Provider Name (Legal Business Name): CAROLINAS PHYSICIANS NETWORK INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2010
Last Update Date: 06/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 COURT DR SUITE 203
GASTONIA NC
28054-2152
US

IV. Provider business mailing address

PO BOX 601067
CHARLOTTE NC
28260-1067
US

V. Phone/Fax

Practice location:
  • Phone: 704-373-0212
  • Fax: 704-342-5871
Mailing address:
  • Phone: 704-373-0212
  • Fax: 704-342-5871

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DANIEL L WIENS
Title or Position: SENIOR VICE PRESIDENT OPERATIONS
Credential:
Phone: 704-355-0648