Provider Demographics
NPI:1437474244
Name:NORTHCROSS MEDICAL CENTER
Entity Type:Organization
Organization Name:NORTHCROSS MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:LE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-895-3415
Mailing Address - Street 1:16511 NORTHCROSS DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-5021
Mailing Address - Country:US
Mailing Address - Phone:704-895-3415
Mailing Address - Fax:704-895-3416
Practice Address - Street 1:16511 NORTHCROSS DR
Practice Address - Street 2:SUITE A
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-5021
Practice Address - Country:US
Practice Address - Phone:704-895-3415
Practice Address - Fax:704-865-3416
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-05
Last Update Date:2010-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102875 (PROVISIONAL)103TB0200X, 103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitationGroup - Multi-Specialty