MEDICARE: SOUTH EAST MECKLENBURG COUNTY HEALTH DEPARTMENT

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	302R00000X	Health Maintenance Organization		NC

General Provider Information

NPI Number	:	1629322292
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH EAST MECKLENBURG COUNTY HEALTH DEPARTMENT

Provider Business Mailing Address
First Line	:	429 BILLINGSLEY ROAD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28211-1089
Country	:	US
Telephone Number	:	704-336-6404
Fax Number	:

Provider Business Practice Location Address
First Line	:	429 BILLINGSLEY ROAD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28211-1089
Country	:	US
Telephone Number	:	704-336-6404
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MR. PHILIP RICHARD ENDRESS
Credential	:
Telephone Number	:	704-336-8638

Provider Enumeration Date	:	11/05/2012
Last Update Date	:	11/26/2012

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