Provider Demographics
NPI:1538328034
Name:CAROLINAS PHYSICIANS NETWORK INC
Entity Type:Organization
Organization Name:CAROLINAS PHYSICIANS NETWORK INC
Other - Org Name:MAIDEN MEDICAL GROUP
Other - Org Type:Doing Business As
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 602069
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2069
Mailing Address - Country:US
Mailing Address - Phone:828-428-0490
Mailing Address - Fax:828-428-0906
Practice Address - Street 1:510 ISLAND FORD RD
Practice Address - Street 2:
Practice Address - City:MAIDEN
Practice Address - State:NC
Practice Address - Zip Code:28650-8741
Practice Address - Country:US
Practice Address - Phone:828-428-0490
Practice Address - Fax:828-428-0906
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CAROLINAS PHYSICIANS NETWORK INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-09
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5950214Medicaid