Provider Demographics
NPI:1467505016
Name:CMC-NORTHEAST, INC
Entity Type:Organization
Organization Name:CMC-NORTHEAST, INC
Other - Org Name:NE PEDIATRIC NEUROLOGY, HUNTERSVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP PHYSICIAN SERV
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:704-783-4146
Mailing Address - Street 1:16623 BIRKDALE PWKY
Mailing Address - Street 2:SUITE 110, NE PEDIATRIC NEURO, HUNTERSVILLE
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078
Mailing Address - Country:US
Mailing Address - Phone:704-987-4277
Mailing Address - Fax:704-987-5096
Practice Address - Street 1:16623 BIRKDALE PWKY
Practice Address - Street 2:SUITE 110, NE PEDIATRIC NEURO, HUNTERSVILLE
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078
Practice Address - Country:US
Practice Address - Phone:704-987-4277
Practice Address - Fax:704-987-5096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0008XAllopathic & Osteopathic PhysiciansPediatricsNeurodevelopmental DisabilitiesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7837542OtherAETNA
NC015Y1OtherBCBS GROUP ID
NC3555573OtherMAMSI
NC5903854Medicaid
NC566000156075OtherTRICARE STANDARD, NON NWK
NCI912OtherPARTNERS MEDICARE CHOICE