MEDICARE: SAGE E BROOK CNM

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	174400000X	Specialist	126103	NC
2	367A00000X	Advanced Practice Midwife	126103	NC
3	367A00000X	Advanced Practice Midwife	123103	NC
4	367A00000X	Advanced Practice Midwife	104	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	104	OTHER	NC	NC CNM
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	126103	OTHER	NC	RN LICENSE
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1952398729
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAGE E BROOK CNM

Provider Business Mailing Address
First Line	:	PO BOX 601067
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28260-1067
Country	:	US
Telephone Number	:	704-512-5100
Fax Number	:	704-512-5101

Provider Business Practice Location Address
First Line	:	325 HAWTHORNE LN
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28204-2535
Country	:	US
Telephone Number	:	704-973-2106
Fax Number	:	704-973-2395

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/05/2005
Last Update Date	:	10/25/2020

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Directions to “ SAGE E BROOK CNM” Practice Location

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