Provider Demographics
NPI:1154646578
Name:CHARLOTTE MEDICAL CLINIC INC
Entity Type:Organization
Organization Name:CHARLOTTE MEDICAL CLINIC INC
Other - Org Name:CHARLOTTE MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ENTERPRISE EVP
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:RISSMILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-355-8675
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:704-631-0002
Mailing Address - Fax:
Practice Address - Street 1:3025 SPRINGBANK LN
Practice Address - Street 2:STE 100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-3362
Practice Address - Country:US
Practice Address - Phone:704-446-2620
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHARLOTTE MEDICAL CLINIC INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-03-29
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & ImmunologyGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5903118Medicaid
NC1154646578OtherNC MEDICAID DME
SCE04411Medicaid
NC1154646578Medicaid
NC1154646578Medicaid
NC2308414Medicare PIN