Provider Demographics
NPI:1619119906
Name:CMC-NORTHEAST, INC.
Entity Type:Organization
Organization Name:CMC-NORTHEAST, INC.
Other - Org Name:NORTHEAST PLASTIC & RECONSTRUCTIVE SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP PHYSICIAN SERVICES
Authorized Official - Prefix:
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 1:200 MEDICAL PARK DR
Mailing Address - Street 2:SUITE 520
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-2982
Mailing Address - Country:US
Mailing Address - Phone:704-403-2760
Mailing Address - Fax:704-403-2779
Practice Address - Street 1:200 MEDICAL PARK DR
Practice Address - Street 2:SUITE 520
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2982
Practice Address - Country:US
Practice Address - Phone:704-403-2760
Practice Address - Fax:704-403-2779
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CMC - NORTHEAST, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-01
Last Update Date:2010-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5911740Medicaid
NCDF8926OtherRAILROAD MEDICARE PTAN
NC5911740Medicaid