Provider Demographics
NPI:1003256926
Name:CHARLOTTE-MECKLENBURG HOSPITAL AUTHORITY
Entity Type:Organization
Organization Name:CHARLOTTE-MECKLENBURG HOSPITAL AUTHORITY
Other - Org Name:CMC ORTHOPAEDIC SURGERY-UNION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:FORD
Authorized Official - Last Name:LAYMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-631-0002
Mailing Address - Street 1:PO BOX 601888
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1888
Mailing Address - Country:US
Mailing Address - Phone:704-355-5660
Mailing Address - Fax:
Practice Address - Street 1:2700 PROVIDENCE RD S
Practice Address - Street 2:SUITE 180
Practice Address - City:WAXHAW
Practice Address - State:NC
Practice Address - Zip Code:28173-6313
Practice Address - Country:US
Practice Address - Phone:704-863-8750
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHARLOTTE MECKLENBURG HOSPITAL AUTHORITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-06-25
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNPB701Medicaid
NC1003256926Medicaid
NC1003256926Medicaid