Provider Demographics
NPI:1609845049
Name:SHALLOTTE MEDICAL CENTER INC
Entity Type:Organization
Organization Name:SHALLOTTE MEDICAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BERNARD
Authorized Official - Middle Name:LEROY
Authorized Official - Last Name:LANGSTON
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:910-754-8731
Mailing Address - Street 1:PO BOX 2561
Mailing Address - Street 2:SHALLOTTE MEDICAL CENTER INC
Mailing Address - City:SHALLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28459
Mailing Address - Country:US
Mailing Address - Phone:910-754-8731
Mailing Address - Fax:910-754-3153
Practice Address - Street 1:341-A WHITEVILLE RD
Practice Address - Street 2:
Practice Address - City:SHALLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28470
Practice Address - Country:US
Practice Address - Phone:910-754-8731
Practice Address - Fax:910-754-3153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-17
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC344615AMedicaid
NC344615AMedicaid
NC2580353Medicare PIN