Provider Demographics
NPI:1619100062
Name:PHYSICIAN HOME CARE
Entity Type:Organization
Organization Name:PHYSICIAN HOME CARE
Other - Org Name:PHYSICIANS HOME CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PODIATRISTS
Authorized Official - Prefix:DR
Authorized Official - First Name:REGINALD
Authorized Official - Middle Name:BARNETTE
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:DPM
Authorized Official - Phone:704-737-6126
Mailing Address - Street 1:1801 N TRYON ST # 314
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28206-2704
Mailing Address - Country:US
Mailing Address - Phone:704-737-6126
Mailing Address - Fax:
Practice Address - Street 1:1801 N TRYON ST # 314
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28206-2704
Practice Address - Country:US
Practice Address - Phone:704-737-6126
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-02
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7704960Medicaid