Healthcare Provider Details

I. General information

NPI: 1811953995
Provider Name (Legal Business Name): CAROLINA HEART PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 09/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 JOHNS HOPKINS DR
GREENVILLE NC
27834-7222
US

IV. Provider business mailing address

804 JOHNS HOPKINS DR
GREENVILLE NC
27834-7222
US

V. Phone/Fax

Practice location:
  • Phone: 252-757-1000
  • Fax: 252-757-3045
Mailing address:
  • Phone: 252-757-1000
  • Fax: 252-757-3045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. PETER B WAGNER
Title or Position: PRESIDENT
Credential: D.O.
Phone: 252-757-1000