Provider Demographics
NPI:1568401651
Name:CMC-NORTHEAST, INC.
Entity Type:Organization
Organization Name:CMC-NORTHEAST, INC.
Other - Org Name:COPPERFIELD INTERNAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP PHYSICIAN SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:FRIEDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:LOWDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-403-4146
Mailing Address - Street 1:380 COPPERFIELD BLVD NE
Mailing Address - Street 2:COPPERFIELD INTERNAL MEDICINE
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-2402
Mailing Address - Country:US
Mailing Address - Phone:704-403-2200
Mailing Address - Fax:704-403-7264
Practice Address - Street 1:380 COPPERFIELD BLVD NE
Practice Address - Street 2:COPPERFIELD INTERNAL MEDICINE
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2402
Practice Address - Country:US
Practice Address - Phone:704-403-2200
Practice Address - Fax:704-403-7264
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CMC-NORTHEAST, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-05
Last Update Date:2010-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC4116OtherPARTNERS MEDICARE CHOICE
NC890226PMedicaid
NCDF8926OtherRAILROAD MEDICARE PTAN
NC355573OtherMAMSI GROUP NUMBER
NCCC2854OtherRAILROAD MEDICARE
NC5906972Medicaid
NC0226POtherBCBS EFF PRIOR TO 7-1-07
NC019GTOtherBCBS EFF 7-1-07
NC566000156018OtherTRICARE STANDARD, NON NWK
NC566000156018OtherTRICARE STANDARD, NON NWK
NC=========001OtherTRICARE EFFECTIVE 7/1/07
NC2325363Medicare ID - Type UnspecifiedGROUP ID