Provider Demographics
NPI:1407086093
Name:CMC-NORTHEAST, INC.
Entity Type:Organization
Organization Name:CMC-NORTHEAST, INC.
Other - Org Name:ROCKY RIVER PEDIATRICS
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:M
Authorized Official - Last Name:LOWDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-403-4146
Mailing Address - Street 1:5427 HIGHWAY 49 S
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:NC
Mailing Address - Zip Code:28075-7408
Mailing Address - Country:US
Mailing Address - Phone:704-455-5565
Mailing Address - Fax:704-455-6225
Practice Address - Street 1:5427 HIGHWAY 49 S
Practice Address - Street 2:ROCKY RIVER PEDIATRICS
Practice Address - City:HARRISBURG
Practice Address - State:NC
Practice Address - Zip Code:28075-7408
Practice Address - Country:US
Practice Address - Phone:704-455-5565
Practice Address - Fax:704-455-6225
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CMC-NORTHEAST, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-07-17
Last Update Date:2010-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCDF8926OtherRAILROAD MEDICARE PTAN
NC5906981Medicaid