=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790024669
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAROLINAS PHYSICIANS NETWORK INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2013
-----------------------------------------------------
Last Update Date | 03/08/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1423 E FRANKLIN ST STE F
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28112-5100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-667-1270
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 19305
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28219-9305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-667-1270
-----------------------------------------------------
Fax | 704-667-1271
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EVP & CHIEF PHYSICIAN EXECUTIVE
-----------------------------------------------------
Name | DR. SCOTT RISSMILLER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 704-446-3507
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------