Provider Demographics
NPI:1376819649
Name:CAROLINAS MEDICAL CENTER-NORTHEAST
Entity Type:Organization
Organization Name:CAROLINAS MEDICAL CENTER-NORTHEAST
Other - Org Name:NORTHEAST PLASTIC & RECONSTRUCTIVE SURGERY-ALBEMARLE
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:MILLER
Authorized Official - Last Name:LOWDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-403-4146
Mailing Address - Street 1:105 YADKIN STREET
Mailing Address - Street 2:SUITE 203
Mailing Address - City:ALBEMARLE
Mailing Address - State:NC
Mailing Address - Zip Code:28001-3459
Mailing Address - Country:US
Mailing Address - Phone:704-403-2760
Mailing Address - Fax:704-403-2779
Practice Address - Street 1:105 YADKIN STREET
Practice Address - Street 2:SUITE 203
Practice Address - City:ALBEMARLE
Practice Address - State:NC
Practice Address - Zip Code:28001-3459
Practice Address - Country:US
Practice Address - Phone:704-403-2760
Practice Address - Fax:704-403-2779
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CAROLINAS MEDICAL CENTER-NORTHEAST
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-03-30
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5920089Medicaid
NC232009OtherMEDICARE PTAN, GROUP