Provider Demographics
NPI:1275596439
Name:CAROLINA SPECIALTY CARE, PA
Entity Type:Organization
Organization Name:CAROLINA SPECIALTY CARE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:I
Authorized Official - Last Name:WODECKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-872-8711
Mailing Address - Street 1:124 SUNSET HILL RD
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28625-2729
Mailing Address - Country:US
Mailing Address - Phone:704-872-8711
Mailing Address - Fax:704-872-5866
Practice Address - Street 1:124 SUNSET HILL DR
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625-2729
Practice Address - Country:US
Practice Address - Phone:704-872-8711
Practice Address - Fax:704-872-5866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-10
Last Update Date:2009-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC36856173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89014TRMedicaid
NC89014TRMedicaid
NC4980030002Medicare NSC
NC2334530Medicare PIN