Provider Demographics
NPI:1275681751
Name:THE CHARLOTTE-MECKLENBURG HOSPITAL AUTHORITY
Entity Type:Organization
Organization Name:THE CHARLOTTE-MECKLENBURG HOSPITAL AUTHORITY
Other - Org Name:MERCY HORIZON OUTPATIENT SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMBAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-355-2154
Mailing Address - Street 1:PO BOX 32861
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28232-2861
Mailing Address - Country:US
Mailing Address - Phone:704-512-6438
Mailing Address - Fax:704-512-6485
Practice Address - Street 1:7825 BALLANTYNE COMMONS PKWY
Practice Address - Street 2:SUITE 110
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-3174
Practice Address - Country:US
Practice Address - Phone:704-446-0391
Practice Address - Fax:704-348-4057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL060577261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300444GMedicaid
NC8300444PMedicaid
NC8300444QMedicaid