Provider Demographics
NPI:1124357124
Name:SHILAND FAMILY MEDICINE
Entity Type:Organization
Organization Name:SHILAND FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VICE PRESIDENT OF OPERATIONS
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 60114
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0114
Mailing Address - Country:US
Mailing Address - Phone:803-329-5131
Mailing Address - Fax:803-366-6600
Practice Address - Street 1:13640 STEELECROFT PKWY
Practice Address - Street 2:SUITE 320
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28278-7565
Practice Address - Country:US
Practice Address - Phone:803-329-5131
Practice Address - Fax:803-366-6600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-22
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNPB357Medicaid
SCNPB357Medicaid