Provider Demographics
NPI:1497788079
Name:PIEDMONT GYNECOLOGICAL AND OBSTETRICAL ASSOCIATES
Entity Type:Organization
Organization Name:PIEDMONT GYNECOLOGICAL AND OBSTETRICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:WIENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-355-0648
Mailing Address - Street 1:PO BOX 601067
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1067
Mailing Address - Country:US
Mailing Address - Phone:803-835-0434
Mailing Address - Fax:704-512-2731
Practice Address - Street 1:704 GOLD HILL ROAD
Practice Address - Street 2:STE 215
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29715-8907
Practice Address - Country:US
Practice Address - Phone:803-835-0434
Practice Address - Fax:704-512-2731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPA6136Medicaid
NC89013AHMedicaid
NC89013AJMedicaid
NC89013AHMedicaid
NC89013AJMedicaid
NC2308441Medicare PIN
NCCJ4433Medicare PIN