Healthcare Provider Details

I. General information

NPI: 1780913921
Provider Name (Legal Business Name): CHARLOTTE MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2009
Last Update Date: 10/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10545 BLAIR ROAD SUITE 2100
MINT HILL NC
28227-2804
US

IV. Provider business mailing address

PO BOX 601643
CHARLOTTE NC
28260-1643
US

V. Phone/Fax

Practice location:
  • Phone: 704-863-9500
  • Fax: 704-863-9501
Mailing address:
  • Phone: 704-512-4808
  • Fax: 704-512-4838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNC

VIII. Authorized Official

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