Provider Demographics
NPI:1518405257
Name:CAROLINAS PHYSICIANS NETWORK INC
Entity Type:Organization
Organization Name:CAROLINAS PHYSICIANS NETWORK INC
Other - Org Name:CAROLINAS HEALTHCARE SYSTEM DIABETES CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ENTERPRISE EVP
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:RISSMILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-355-8675
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:704-631-0002
Mailing Address - Fax:
Practice Address - Street 1:4525 CAMERON VALLEY PKWY
Practice Address - Street 2:STE 4100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-4369
Practice Address - Country:US
Practice Address - Phone:704-302-9462
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CAROLINAS PHYSICIANS NETWORK INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-02-02
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNPB847Medicaid
SCNPB844Medicaid
NC1518405257Medicaid
SCNPB841Medicaid
SCNPB842Medicaid
SCNPB843Medicaid
SCNPB845Medicaid
SCNPB846Medicaid
SCNPB840Medicaid
SCNPB841Medicaid