=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598257750
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BALSAM HEALTH OF THE CAROLINAS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2018
-----------------------------------------------------
Last Update Date | 06/04/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 607 W GROVER ST STE 101
-----------------------------------------------------
City | SHELBY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28150-2816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-866-0101
-----------------------------------------------------
Fax | 704-866-0103
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 6449
-----------------------------------------------------
City | CONCORD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28027-1525
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-866-0101
-----------------------------------------------------
Fax | 704-866-0103
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MEMBER
-----------------------------------------------------
Name | RADWAN IBRAHIM
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 704-941-4485
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 9701414
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------