MEDICARE: CMC-NORTHEAST, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084N0402X	Neurology with Special Qualifications in Child Neurology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043525280
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CMC-NORTHEAST, INC.

Provider Business Mailing Address
First Line	:	6600 WILKINSON BLVD
Second Line	:	CAROLINAS PEDIATRIC NEUROLOGY CARE - HOLY ANGELS
City	:	BELMONT
State	:	NC
Zip	:	28012-2796
Country	:	US
Telephone Number	:	704-446-1900
Fax Number	:	704-446-6255

Provider Business Practice Location Address
First Line	:	6600 WILKINSON BLVD
Second Line	:	CAROLINAS PEDIATRIC NEUROLOGY CARE - HOLY ANGELS
City	:	BELMONT
State	:	NC
Zip	:	28012-2796
Country	:	US
Telephone Number	:	704-446-1900
Fax Number	:	704-446-6255

Authorized Official
Title or Position	:	SR VP
Name	:	FRIEDA M LOWDER
Credential	:
Telephone Number	:	704-403-4146

Provider Enumeration Date	:	08/12/2010
Last Update Date	:	11/15/2011

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Directions to “CMC-NORTHEAST, INC. ” Practice Location

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