=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255364535
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MECKLENBURG MEDICAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2006
-----------------------------------------------------
Last Update Date | 03/06/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7903 PROVIDENCE RD SUITE 100
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28277-9720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-367-8610
-----------------------------------------------------
Fax | 704-367-6798
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 601643
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28260-1643
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-367-8610
-----------------------------------------------------
Fax | 704-367-6798
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SENIOR VICE PRESIDENT
-----------------------------------------------------
Name | DANIEL L WIENS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 704-355-0648
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RE0101X
-----------------------------------------------------
Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 207RH0003X
-----------------------------------------------------
Taxonomy Name | Hematology & Oncology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 207RI0200X
-----------------------------------------------------
Taxonomy Name | Infectious Disease Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 207RP1001X
-----------------------------------------------------
Taxonomy Name | Pulmonary Disease Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #8
-----------------------------------------------------
Taxonomy Code | 207RR0500X
-----------------------------------------------------
Taxonomy Name | Rheumatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #9
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------