Provider Demographics
NPI:1083696926
Name:TENET CENTRAL CAROLINA PHYSICIANS INC
Entity Type:Organization
Organization Name:TENET CENTRAL CAROLINA PHYSICIANS INC
Other - Org Name:MID CAROLINA CROSSROADS SURGICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP OF OUTPATIENT SERVICES, TENET
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:KYLE
Authorized Official - Last Name:BURTNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-893-2153
Mailing Address - Street 1:PO BOX 741608
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-1608
Mailing Address - Country:US
Mailing Address - Phone:919-774-1277
Mailing Address - Fax:919-774-1101
Practice Address - Street 1:709 WICKER ST
Practice Address - Street 2:STE B
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330-4142
Practice Address - Country:US
Practice Address - Phone:919-774-1277
Practice Address - Fax:919-774-1101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-16
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5903334Medicaid
DF0988OtherRAILROAD MEDICARE
NC017MYOtherBCBS
NC5903334Medicaid