Provider Demographics
NPI:1629318886
Name:COLUMBUS REGIONAL HEALTH NETWORK
Entity Type:Organization
Organization Name:COLUMBUS REGIONAL HEALTH NETWORK
Other - Org Name:SOUTH COLUMBUS MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VICE PRESIDENT/OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:WIENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-355-0648
Mailing Address - Street 1:PO BOX 602530
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2530
Mailing Address - Country:US
Mailing Address - Phone:910-653-7000
Mailing Address - Fax:910-635-7004
Practice Address - Street 1:14508 JAMES B WHITE HWY S
Practice Address - Street 2:
Practice Address - City:TABOR CITY
Practice Address - State:NC
Practice Address - Zip Code:28463-8358
Practice Address - Country:US
Practice Address - Phone:910-653-7000
Practice Address - Fax:910-653-7004
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLUMBUS REGIONAL HEALTH NETWORK
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-02-26
Last Update Date:2013-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1629318886Medicaid
NC2335908Medicare PIN