Basic Information
| Provider Information | |||||||||
| NPI: | 1386071967 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE CHARLOTTE-MECKLENBURG HOSPITAL AUTHORITY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | NORTHEAST NEUROLOGY-COPPERFIELD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 270 COPPERFIELD BLVD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280252444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7044031911 | ||||||||
| FaxNumber: | 7044031901 | ||||||||
| Practice Location | |||||||||
| Address1: | 270 COPPERFIELD BLVD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280252444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7044031911 | ||||||||
| FaxNumber: | 7044031901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2013 | ||||||||
| LastUpdateDate: | 01/21/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LOWDER | ||||||||
| AuthorizedOfficialFirstName: | FRIEDA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | SR. VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7044031780 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | THE CHARLOTTE-MECKLENBURG HOSPITAL AUTHORITY | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.