Provider Demographics
NPI:1073562757
Name:MID-ATLANTIC EMERGENCY MEDICAL ASSOCIATES, PLLC
Entity Type:Organization
Organization Name:MID-ATLANTIC EMERGENCY MEDICAL ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:ICENHOUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-319-5822
Mailing Address - Street 1:501 S SHARON AMITY RD STE 300
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-0035
Mailing Address - Country:US
Mailing Address - Phone:704-377-2424
Mailing Address - Fax:704-377-2687
Practice Address - Street 1:501 S SHARON AMITY RD STE 300
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211
Practice Address - Country:US
Practice Address - Phone:704-377-2424
Practice Address - Fax:704-377-2687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0294WOtherBCBSNC
NC89-016RMMedicaid
NCCI1307OtherRR MEDICARE
SCQPA372Medicaid
NC89-0294WMedicaid
NC89-0295GMedicaid
SCNPA807Medicaid
SCQPA373Medicaid
NC89-0295HMedicaid
SCNPA822Medicaid
NC89-01401Medicaid
NC89-0294WMedicaid