Provider Demographics
NPI:1073540365
Name:UNION FAMILY PRACTICE
Entity Type:Organization
Organization Name:UNION FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:WIENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-355-0648
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:704-289-5443
Mailing Address - Fax:704-283-7655
Practice Address - Street 1:1106 REYNOLDS STREET
Practice Address - Street 2:SUITE 100
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112-4376
Practice Address - Country:US
Practice Address - Phone:704-289-5443
Practice Address - Fax:704-283-7655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2013-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNPB206Medicaid
NC5905686Medicaid
NC5905686Medicaid
SCNPB206Medicaid
NC2331634AMedicare PIN