MEDICARE: CHARLOTTE'S PREMIERE HEALTHCARE

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	207Q00000X	Family Medicine Physician	36420	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
2	013UN	OTHER	NC	BLUE CROSS BLE SHIELD ID

General Provider Information

NPI Number	:	1548337702
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHARLOTTE'S PREMIERE HEALTHCARE

Provider Business Mailing Address
First Line	:	3230 PROSPERITY CHURCH RD
Second Line	:	SUITE 101
City	:	CHARLOTTE
State	:	NC
Zip	:	28269-8251
Country	:	US
Telephone Number	:	704-510-4366
Fax Number	:	704-510-4347

Provider Business Practice Location Address
First Line	:	3230 PROSPERITY CHURCH RD
Second Line	:	SUITE 101
City	:	CHARLOTTE
State	:	NC
Zip	:	28269-8251
Country	:	US
Telephone Number	:	704-510-4366
Fax Number	:	704-510-4347

Authorized Official
Title or Position	:	DOCTOR
Name	:	DR. CAROL ANNE RUPE
Credential	:	M.D.
Telephone Number	:	704-510-4366

Provider Enumeration Date	:	11/30/2006
Last Update Date	:	10/22/2007

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