Provider Demographics
NPI:1497073431
Name:CMC NORTHEAST
Entity Type:Organization
Organization Name:CMC NORTHEAST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RESIDENCY COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JACKQUELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:HARVE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-721-2063
Mailing Address - Street 1:PO BOX 129
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:NC
Mailing Address - Zip Code:27551-0129
Mailing Address - Country:US
Mailing Address - Phone:252-767-8877
Mailing Address - Fax:252-257-3400
Practice Address - Street 1:270 COPPERFIELD BLVD NE
Practice Address - Street 2:SUITE 202
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2441
Practice Address - Country:US
Practice Address - Phone:704-721-2063
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-15
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty