MEDICARE: PIEDMONT GYNECOLOGICAL AND OBSTETRICAL ASSOCIATES

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	207V00000X	Obstetrics & Gynecology 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
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1497788079
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PIEDMONT GYNECOLOGICAL AND OBSTETRICAL ASSOCIATES

Provider Business Mailing Address
First Line	:	PO BOX 601067
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28260-1067
Country	:	US
Telephone Number	:	803-835-0434
Fax Number	:	704-512-2731

Provider Business Practice Location Address
First Line	:	704 GOLD HILL ROAD
Second Line	:	STE 215
City	:	FORT MILL
State	:	SC
Zip	:	29715-8907
Country	:	US
Telephone Number	:	803-835-0434
Fax Number	:	704-512-2731

Authorized Official
Title or Position	:	SENIOR VICE PRESIDENT
Name	:	DANIEL L WIENS
Credential	:
Telephone Number	:	704-355-0648

Provider Enumeration Date	:	07/08/2006
Last Update Date	:	11/28/2012

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