MEDICARE: CAROLINA NEUROLOGICAL CLINIC, PA

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	2084N0400X	Neurology Physician

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	:	1902861396
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAROLINA NEUROLOGICAL CLINIC, PA

Provider Business Mailing Address
First Line	:	PO BOX 221009
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28222-1009
Country	:	US
Telephone Number	:	704-377-9323
Fax Number	:	704-331-4030

Provider Business Practice Location Address
First Line	:	3541 RANDOLPH RD
Second Line	:	SUITE 101
City	:	CHARLOTTE
State	:	NC
Zip	:	28211-1082
Country	:	US
Telephone Number	:	704-377-9323
Fax Number	:	704-331-4030

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	SHEPARD AVERITT
Credential	:
Telephone Number	:	704-377-9323

Provider Enumeration Date	:	04/19/2006
Last Update Date	:	08/22/2020

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