MEDICARE: BEHAVIORAL HEALTH CENTER CMC RANDOLPH

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	261QM0850X	Adult Mental Health Clinic/Center	H0071	NC

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

General Provider Information

NPI Number	:	1497952709
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEHAVIORAL HEALTH CENTER CMC RANDOLPH

Provider Business Mailing Address
First Line	:	501 BILLINGSLEY RD
Second Line	:	BEHAVIORAL HEALTH CENTER CMC RANDOLPH
City	:	CHARLOTTE
State	:	NC
Zip	:	28211-1009
Country	:	US
Telephone Number	:	704-358-2710
Fax Number	:	704-358-2938

Provider Business Practice Location Address
First Line	:	1216 N TRYON ST
Second Line	:	BEHAVIORAL HEALTH CENTER CMC RANDOLPH
City	:	CHARLOTTE
State	:	NC
Zip	:	28206-3256
Country	:	US
Telephone Number	:	704-336-6570
Fax Number	:	704-336-3623

Authorized Official
Title or Position	:	ASSISTANT VICE PRESIDENT
Name	:	THOMAS E. GETTELMAN
Credential	:	PH.D.
Telephone Number	:	704-444-2406

Provider Enumeration Date	:	06/29/2007
Last Update Date	:	10/18/2007

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