Basic Information
Provider Information
NPI: 1003801606
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: LEVY
FirstName: FREDERIC
MiddleName: EVAN
NamePrefix:  
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2520 ABERDEEN BLVD
Address2:  
City: GASTONIA
State: NC
PostalCode: 280540635
CountryCode: US
TelephoneNumber: 7048688400
FaxNumber: 7048688493
Practice Location
Address1: 2520 ABERDEEN BLVD
Address2:  
City: GASTONIA
State: NC
PostalCode: 280540635
CountryCode: US
TelephoneNumber: 7048688400
FaxNumber: 7048688493
Other Information
ProviderEnumerationDate: 09/20/2005
LastUpdateDate: 07/09/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: X
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
174400000X94-00559NCY Other Service ProvidersSpecialist 

ID Information
IDTypeStateIssuerDescription
210380001NCMAMSIOTHER
5177X01NCBLUE CROSS BLUE SHIELDOTHER
7258601NCMEDCOSTOTHER
895177X05NC MEDICAID
N0055901SCSOUTH CAROLINA MEDICAIDOTHER
208488700501NCCIGNA HEALTHCAREOTHER
34300201NCCOVENTRY HEALTHCAREOTHER
1153601NCPARTNERS HEALTHPLANOTHER
10-4116201NCUNITED HEALTHCAREOTHER
16823501NCMIDSOUTHOTHER
203168501NCAETNA HEALTHPLANOTHER


Home