=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760810501
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHARLOTTE-MECKLENBURG HOSPITAL AUTHORITY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2013
-----------------------------------------------------
Last Update Date | 10/14/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9625 NORTHCROSS CENTER CT SUITE 102
-----------------------------------------------------
City | HUNTERSVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28078-7348
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-381-8840
-----------------------------------------------------
Fax | 704-381-8836
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 602120
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28260-2120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-381-8840
-----------------------------------------------------
Fax | 704-381-8836
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CMC - LINCOLN
-----------------------------------------------------
Name | PETER W ACKER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 980-212-1000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RS0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------