Provider Demographics
NPI:1386840627
Name:CMC-NORTHEAST, INC.
Entity Type:Organization
Organization Name:CMC-NORTHEAST, INC.
Other - Org Name:CAROLINA PEDIATRIC SURGERY - HUNTERSVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP PHYSICIAN SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:FRIEDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:LOWDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-403-4146
Mailing Address - Street 1:9625 NORTHCROSS CENTER CT
Mailing Address - Street 2:SUITE 102-A
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-7348
Mailing Address - Country:US
Mailing Address - Phone:704-801-1240
Mailing Address - Fax:704-801-1241
Practice Address - Street 1:9625 NORTHCROSS CENTER CT
Practice Address - Street 2:SUITE 102-A
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-7348
Practice Address - Country:US
Practice Address - Phone:704-801-1240
Practice Address - Fax:704-801-1241
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CMC-NORTHEAST, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-25
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC019FNOtherBCBS EFF 7-1-07
SCQPB706Medicaid
NC5914359OtherMEDICAID, GROUP, EFF 5/1/09
NC017CPOtherBCBS EFF PRIOR TO 7-1-07
NC355573OtherMAMSI
NC5906850Medicaid