Provider Demographics
NPI:1629305073
Name:MECKLENBURG MEDICAL GROUP
Entity Type:Organization
Organization Name:MECKLENBURG MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR. VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WIENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-355-0648
Mailing Address - Street 1:PO BOX 60063
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0063
Mailing Address - Country:US
Mailing Address - Phone:704-512-4808
Mailing Address - Fax:
Practice Address - Street 1:13640 STEELECROFT PARKWAY
Practice Address - Street 2:SUITE 320
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28278-7565
Practice Address - Country:US
Practice Address - Phone:704-302-8900
Practice Address - Fax:704-302-8901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-05
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty