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General NPI Number Information
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NPI Number | 1669797536
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Entity Type | Organization
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Legal Business Name | MECKLENBURG MEDICAL GROUP
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Dates
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Enumeration Date | 04/02/2010
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Last Update Date | 04/02/2010
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Provider Practice Location Address
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Address Line | 16455 STATESVILLE ROAD SUITE 200
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City | HUNTERSVILLE
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State | NC
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Zip | 28078-7125
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Country | US
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Telephone | 704-367-6610
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Fax | 704-367-6650
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Provider Business Mailing Address
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Address Line | PO BOX 60063
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City | CHARLOTTE
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State | NC
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Zip | 28260-0063
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Country | US
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Telephone | 704-367-6610
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Fax | 704-367-6650
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Authorized Official
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Title or Position | SENIOR VICE PRESIDENT
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Name | DANIEL L WIENS
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Credential |
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Telephone | 704-355-0648
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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