Provider Demographics
NPI:1124544499
Name:CAROLINA CONCUSSION & PHYSICAL MEDICINE, PLLC
Entity Type:Organization
Organization Name:CAROLINA CONCUSSION & PHYSICAL MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:DECRISCIO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:301-922-6188
Mailing Address - Street 1:7900 WOODCROSS WAY
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-8328
Mailing Address - Country:US
Mailing Address - Phone:301-922-6188
Mailing Address - Fax:
Practice Address - Street 1:120 CAPCOM AVEUNE
Practice Address - Street 2:SUITE 104
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587
Practice Address - Country:US
Practice Address - Phone:301-922-6188
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-18
Last Update Date:2018-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4670111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty