Provider Demographics
NPI:1346226024
Name:CABARRUS UROLOGY CLINIC PA
Entity Type:Organization
Organization Name:CABARRUS UROLOGY CLINIC PA
Other - Org Name:NORTHEAST UROLOGY ASSOCIATES PA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:CAMERON
Authorized Official - Middle Name:TRENT
Authorized Official - Last Name:BLACKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-786-5131
Mailing Address - Street 1:1084 VINEHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-2438
Mailing Address - Country:US
Mailing Address - Phone:704-786-5131
Mailing Address - Fax:704-784-4129
Practice Address - Street 1:1084 VINEHAVEN DR
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2438
Practice Address - Country:US
Practice Address - Phone:704-786-5131
Practice Address - Fax:704-784-4129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8901152Medicaid
NC230207Medicare ID - Type Unspecified