WESTERN CAROLINA CARDIOLOGY

Provider Demographics

• NPI: 1164466447
• Name: WESTERN CAROLINA CARDIOLOGY
• Entity Type: Organization
• Organization Name: WESTERN CAROLINA CARDIOLOGY
• Authorized Official - Title/Position: PARTNER
• Authorized Official - Prefix: MR
• Authorized Official - First Name: DAVID
• Authorized Official - Middle Name: W
• Authorized Official - Last Name: PETERSON
• Authorized Official - Credentials: MD
• Authorized Official - Phone: 828-564-9222
• Mailing Address - Street 1: 32 PHYSICIAN DR
• Mailing Address - City: CLYDE
• Mailing Address - State: NC
• Mailing Address - Zip Code: 28721-8486
• Mailing Address - Country: US
• Mailing Address - Phone: 828-564-9222
• Mailing Address - Fax: 828-564-9228
• Practice Address - Street 1: 32 PHYSICIAN DR
• Practice Address - City: CLYDE
• Practice Address - State: NC
• Practice Address - Zip Code: 28721-8486
• Practice Address - Country: US
• Practice Address - Phone: 828-564-9222
• Practice Address - Fax: 828-564-9228
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2006-06-16
• Last Update Date: 2009-11-10

Provider Licenses

State	License ID	Taxonomies
NC	9801441	174400000X
NC	200000225	174400000X
NC	200200031	174400000X
NC	2009-01377	207RC0000X
NC	0050-02618	363L00000X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	174400000X	Other Service Providers	Specialist		Group - Single Specialty
No	207RC0000X	Allopathic & Osteopathic Physicians	Internal Medicine	Cardiovascular Disease	Group - Single Specialty
No	363L00000X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner		Group - Single Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
NC	89126HP	Medicaid
NC	5900317	Medicaid
NC	89130MM	Medicaid
NC	2038236	Medicare ID - Type Unspecified
NC	5900317	Medicaid
NC	89130MM	Medicaid
NC	060069474	Medicare PIN
NC	D45504	Medicare UPIN
NC	F86263	Medicare UPIN
NC	2280046B	Medicare ID - Type Unspecified
NC	P00198068	Medicare PIN