Basic Information
| Provider Information | |||||||||
| NPI: | 1740236041 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAROLINAS MEDICAL CENTER-NORTHEAST | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NORTHEAST NEUROLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 315 MEDICAL PARK DR | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280252973 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7044031911 | ||||||||
| FaxNumber: | 7044031901 | ||||||||
| Practice Location | |||||||||
| Address1: | 315 MEDICAL PARK DR | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280252973 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7044031911 | ||||||||
| FaxNumber: | 7044031901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 03/15/2013 | ||||||||
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| AuthorizedOfficialLastName: | LOWDER | ||||||||
| AuthorizedOfficialFirstName: | FRIEDA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | VP PHYSICIAN SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 7044034146 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CAROLINAS MEDICAL CENTER-NORTHEAST | ||||||||
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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 |
ID Information
| ID | Type | State | Issuer | Description | 566000156023 | 01 | NC | TRICARE STANDARD, NON NWK | OTHER | 355573 | 01 | NC | MAMSI | OTHER | CC2854 | 01 | NC | RAILROAD MEDICARE | OTHER | 01895 | 01 | NC | BCBS EFF PRIOR TO 7-1-07 | OTHER | 7901895 | 05 | NC | MEDICAID | 5906955 | 05 | NC | MEDICAID | 019GN | 01 | NC | BCBS EFF 7-1-07 | OTHER | 8599 | 01 | NC | PARTNERS MEDICARE CHOICE | OTHER | DF8926 | 01 | NC | RAILROAD MEDICARE PTAN | OTHER |