Provider Demographics
NPI:1174823900
Name:CMC-NORTHEAST, INC.
Entity Type:Organization
Organization Name:CMC-NORTHEAST, INC.
Other - Org Name:CAROLINAS PEDIATRIC NEUROLOGY CARE - GASTONIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FRIEDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:LOWDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-403-4146
Mailing Address - Street 1:2550 COURT DR
Mailing Address - Street 2:SUITE 203
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-2152
Mailing Address - Country:US
Mailing Address - Phone:704-403-2660
Mailing Address - Fax:704-403-2670
Practice Address - Street 1:2550 COURT DR
Practice Address - Street 2:SUITE 203
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2152
Practice Address - Country:US
Practice Address - Phone:704-403-2660
Practice Address - Fax:704-403-2670
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CMC-NORTHEAST, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-10-27
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child NeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNPB455Medicaid
NC5916350Medicaid