Provider Demographics
NPI:1609880566
Name:OWEIDA AND CHRISTIAN ORTHOPAEDIC & SPORTS MEDICINE,PA
Entity Type:Organization
Organization Name:OWEIDA AND CHRISTIAN ORTHOPAEDIC & SPORTS MEDICINE,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:HAGLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-944-7313
Mailing Address - Street 1:3541 RANDOLPH RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-1082
Mailing Address - Country:US
Mailing Address - Phone:704-944-0143
Mailing Address - Fax:704-944-7399
Practice Address - Street 1:3541 RANDOLPH RD
Practice Address - Street 2:SUITE 210
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1082
Practice Address - Country:US
Practice Address - Phone:704-944-0143
Practice Address - Fax:704-944-7399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC28788174400000X
NC201593174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890238KMedicaid
NC890238KMedicaid
NC=========OtherTAX ID NUMBER
NC2309532Medicare PIN
NC6443790001Medicare NSC