Provider Demographics
NPI:1366684771
Name:CHARLOTTE SPORTS MEDICINE INSTITUTE, P.A.
Entity Type:Organization
Organization Name:CHARLOTTE SPORTS MEDICINE INSTITUTE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:PAUL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-509-6427
Mailing Address - Street 1:10616 METROMONT PKWY
Mailing Address - Street 2:SUITE 106
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-7656
Mailing Address - Country:US
Mailing Address - Phone:704-509-6427
Mailing Address - Fax:704-509-6964
Practice Address - Street 1:10616 METROMONT PKWY
Practice Address - Street 2:SUITE 106
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-7656
Practice Address - Country:US
Practice Address - Phone:704-509-6427
Practice Address - Fax:704-509-6964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-31
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC009700704207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891051MMedicaid
NC1051MOtherBCBS
NC2239912AMedicare PIN
NC891051MMedicaid