Provider Demographics
NPI:1578572939
Name:UNION PHYSICIANS NETWORK INC
Entity Type:Organization
Organization Name:UNION PHYSICIANS NETWORK INC
Other - Org Name:LAKE PARK FAMILY PRACTICE
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 60643
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0643
Mailing Address - Country:US
Mailing Address - Phone:704-882-1666
Mailing Address - Fax:704-882-2789
Practice Address - Street 1:6208 CREFT CIR
Practice Address - Street 2:SUITE 222
Practice Address - City:INDIAN TRAIL
Practice Address - State:NC
Practice Address - Zip Code:28079-9003
Practice Address - Country:US
Practice Address - Phone:704-882-1666
Practice Address - Fax:704-882-2789
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNION PHYSICIANS NETWORK INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-05
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7705363OtherNC MEDICAID DME SUPPLIER
NC014PKOtherBLUE CROSS - BLUE SHIELD
NC89014PKMedicaid
NC89014PKMedicaid
NC5701240001Medicare NSC