MEDICARE: CAROLINA MEDICORP ENTERPRISES, 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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1649512922
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAROLINA MEDICORP ENTERPRISES, INC

Provider Business Mailing Address
First Line	:	PO BOX 751803
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28275-1803
Country	:	US
Telephone Number	:	336-893-3270
Fax Number	:

Provider Business Practice Location Address
First Line	:	4136 CLEMMONS RD
Second Line	:
City	:	CLEMMONS
State	:	NC
Zip	:	27012-7520
Country	:	US
Telephone Number	:	336-893-3270
Fax Number	:

Authorized Official
Title or Position	:	VP OF NMG FINANCE
Name	:	GEOFFREY K GARDNER
Credential	:
Telephone Number	:	704-384-9144

Provider Enumeration Date	:	03/25/2013
Last Update Date	:	03/31/2016

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