Provider Demographics
NPI:1134477466
Name:CAROLINAS PHYSICIANS NETWORK INC
Entity Type:Organization
Organization Name:CAROLINAS PHYSICIANS NETWORK INC
Other - Org Name:UNION SURGICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
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:704-667-6700
Mailing Address - Fax:704-667-6701
Practice Address - Street 1:2700 PROVIDENCE RD S
Practice Address - Street 2:SUITE 225
Practice Address - City:WAXHAW
Practice Address - State:NC
Practice Address - Zip Code:28173-6313
Practice Address - Country:US
Practice Address - Phone:704-667-6700
Practice Address - Fax:704-667-6701
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CAROLINAS PHYSICIANS NETWORK INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-08-16
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5919558Medicaid
SCNPB468Medicaid
SCNPB468Medicaid