=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184748519
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MECKLENBURG PULMONARY SPECIALISTS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2007
-----------------------------------------------------
Last Update Date | 02/05/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2711 RANDOLPH RD STE 208
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28207-2034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-926-5433
-----------------------------------------------------
Fax | 704-926-5460
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2711 RANDOLPH RD STE 208
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28207-2034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-926-5433
-----------------------------------------------------
Fax | 704-926-5460
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CARL SMART
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 704-926-5469
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 9400640
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------