Provider Demographics
NPI:1639492176
Name:CAROLINA HEALTHCARE ASSOCIATES, INC.
Entity Type:Organization
Organization Name:CAROLINA HEALTHCARE ASSOCIATES, INC.
Other - Org Name:ROBERT T. BENNETT, MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:GOODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-667-7597
Mailing Address - Street 1:PO BOX 602484
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2484
Mailing Address - Country:US
Mailing Address - Phone:910-763-6257
Mailing Address - Fax:910-343-0171
Practice Address - Street 1:1333 S DICKINSON DRIVE
Practice Address - Street 2:SUITE 230
Practice Address - City:LELAND
Practice Address - State:NC
Practice Address - Zip Code:28451-6434
Practice Address - Country:US
Practice Address - Phone:910-763-6257
Practice Address - Fax:910-343-0171
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CAROLINAS HEALTHCARE ASSOCIATES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-03-11
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1639492176Medicaid
NC5914427Medicaid
NC1639492176Medicaid