Provider Demographics
NPI:1548571672
Name:CPSC CMG LLC
Entity Type:Organization
Organization Name:CPSC CMG LLC
Other - Org Name:CAROLINAS PLASTIC SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT, CEO
Authorized Official - Prefix:
Authorized Official - First Name:VALINDA
Authorized Official - Middle Name:L
Authorized Official - Last Name:RUTLEDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-834-2133
Mailing Address - Street 1:2391 COURT DR
Mailing Address - Street 2:STE 120
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-2196
Mailing Address - Country:US
Mailing Address - Phone:704-874-0095
Mailing Address - Fax:704-866-8680
Practice Address - Street 1:2391 COURT DR
Practice Address - Street 2:STE 120
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2196
Practice Address - Country:US
Practice Address - Phone:704-874-0095
Practice Address - Fax:704-866-8680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-23
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5915163Medicaid
NC5915163Medicaid