MEDICARE: CMC-NORTHEAST, 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	207RP1001X	Pulmonary Disease Physician
2	207R00000X	Internal Medicine Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	CC2854	OTHER	NC	RAILROAD MEDICARE GROUP
6	7232	OTHER	NC	PARTNERS MEDICARE CHOICE
8	DF8926	OTHER	NC	RAILROAD MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	355573	OTHER	NC	MAMSI GROUP NUMBER
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	0279N	OTHER	NC	BCBS EFF PRIOR TO 7-1-07
5	019FP	OTHER	NC	BCBS EFF 7-1-07
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
9	566000156022	OTHER	NC	TRICARE STANDARD, NON NWK

General Provider Information

NPI Number	:	1730128810
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CMC-NORTHEAST, INC.

Provider Business Mailing Address
First Line	:	200 MEDICAL PARK DR
Second Line	:	SUITE 550 CONCORD INTERNAL MEDICINE
City	:	CONCORD
State	:	NC
Zip	:	28025-0926
Country	:	US
Telephone Number	:	704-403-1307
Fax Number	:	704-403-1090

Provider Business Practice Location Address
First Line	:	200 MEDICAL PARK DR
Second Line	:	SUITE 550 CONCORD INTERNAL MEDICINE
City	:	CONCORD
State	:	NC
Zip	:	28025-0926
Country	:	US
Telephone Number	:	704-403-1307
Fax Number	:	704-403-1090

Authorized Official
Title or Position	:	VP PHYSICIAN SERVICES
Name	:	FRIEDA M LOWDER
Credential	:
Telephone Number	:	704-403-4146

Provider Enumeration Date	:	06/05/2006
Last Update Date	:	06/01/2010

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Directions to “CMC-NORTHEAST, INC. ” Practice Location

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