Healthcare Provider Details

I. General information

NPI: 1659339596
Provider Name (Legal Business Name): CAROLINA MEDICORP ENTERPRISES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 06/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 HICKORY BRANCH DR
GREENSBORO NC
27409-9601
US

IV. Provider business mailing address

PO BOX 751803
CHARLOTTE NC
28275-1803
US

V. Phone/Fax

Practice location:
  • Phone: 336-878-2260
  • Fax: 336-878-2277
Mailing address:
  • Phone: 704-716-4820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: GEOFFREY GARDNER
Title or Position: VP FINANCE
Credential:
Phone: 336-878-2260