Provider Demographics
NPI:1003161555
Name:CAROLINAS MEDICAL CENTER-NORTHEAST
Entity Type:Organization
Organization Name:CAROLINAS MEDICAL CENTER-NORTHEAST
Other - Org Name:NORTHEAST DERMATOLOGY-SALISBURY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FRIEDA
Authorized Official - Middle Name:MILLER
Authorized Official - Last Name:LOWDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-403-4146
Mailing Address - Street 1:340 JAKE ALEXANDER BLVD W
Mailing Address - Street 2:SUITE B
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28147-1364
Mailing Address - Country:US
Mailing Address - Phone:704-403-2777
Mailing Address - Fax:704-403-2779
Practice Address - Street 1:340 JAKE ALEXANDER BLVD W
Practice Address - Street 2:SUITE B
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28147-1364
Practice Address - Country:US
Practice Address - Phone:704-403-2777
Practice Address - Fax:704-403-2779
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CAROLINAS MEDICAL CENTER-NORTHEAST
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-07-20
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC232009OtherMEDICARE PTAN, GROUP
NC5921378Medicaid