Provider Demographics
NPI:1164770467
Name:CAROLINAS PHYSICIANS NETWORK INC
Entity Type:Organization
Organization Name:CAROLINAS PHYSICIANS NETWORK INC
Other - Org Name:WESLEY CHAPEL FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATION
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:704-667-4280
Mailing Address - Fax:704-667-4281
Practice Address - Street 1:5955 WEDDINGTON RD
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:NC
Practice Address - Zip Code:28104-6296
Practice Address - Country:US
Practice Address - Phone:704-667-4280
Practice Address - Fax:704-667-4281
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CAROLINAS PHYSICIANS NETWORK INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-08-17
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5917907Medicaid
SCQPB648Medicaid
NC5917907Medicaid