Provider Demographics
NPI:1568424547
Name:CAROLINAS MEDICAL CENTER-NORTHEAST
Entity Type:Organization
Organization Name:CAROLINAS MEDICAL CENTER-NORTHEAST
Other - Org Name:DEVELOPMENT & BEHAVIORAL PEDIATRICS OF THE CAROLINA'S
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP PHYSICIAN SERVICES
Authorized Official - Prefix:MRS
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 1:301 MEDICAL PARK DR
Mailing Address - Street 2:SUITE 202B
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-2981
Mailing Address - Country:US
Mailing Address - Phone:704-403-2626
Mailing Address - Fax:704-784-8615
Practice Address - Street 1:301 MEDICAL PARK DR
Practice Address - Street 2:SUITE 202B
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2981
Practice Address - Country:US
Practice Address - Phone:704-403-2626
Practice Address - Fax:704-784-8615
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CAROLINAS MEDICAL CENTER-NORTHEAST
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-04-05
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral PediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC016GNOtherBCBS GROUP ID
SCQPB658OtherS.C. MEDICAID
NC396408OtherMAMSI GROUP NO
NC89135FEMedicaid
NC561878722001OtherTRICARE STANDARD, NON NWK
NCDF8926OtherRAILROAD MEDICARE PTAN