Basic Information
| Provider Information | |||||||||
| NPI: | 1326079567 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTERNAL MEDICINE SPECIALIST, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3101 LATROBE DR | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282114849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043767362 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3101 LATROBE DR | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282114849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043767362 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 01/15/2008 | ||||||||
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| AuthorizedOfficialLastName: | FRYE | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 7043767362 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8901076 | 05 | NC | MEDICAID | NPB152 | 05 | SC | MEDICAID | 89013WK | 05 | NC | MEDICAID | NPB153 | 05 | SC | MEDICAID | NPB154 | 05 | SC | MEDICAID | 89013WJ | 05 | NC | MEDICAID |