Provider Demographics
NPI:1679512677
Name:CMC-NORTHEAST, INC.
Entity Type:Organization
Organization Name:CMC-NORTHEAST, INC.
Other - Org Name:CAROLINA PEDIATRIC 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 1:100 MEDICAL PARK DR
Mailing Address - Street 2:SUITE 310 -CAROLINA PEDIATRIC SURGERY
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-2966
Mailing Address - Country:US
Mailing Address - Phone:704-403-2660
Mailing Address - Fax:704-403-2670
Practice Address - Street 1:100 MEDICAL PARK DR
Practice Address - Street 2:SUITE 310 -CAROLINA PEDIATRIC SURGERY
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2966
Practice Address - Country:US
Practice Address - Phone:704-403-2660
Practice Address - Fax:704-403-2670
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CMC-NORTHEAST, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-05
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC355573OtherMAMSI
NC019FNOtherBCBS EFF 7-1-07
SCQPB706Medicaid
NCDF8926OtherRAILROAD MEDICARE PTAN
NC241255803OtherTRICARE
NC5901473Medicaid
NC5906961Medicaid
NC017CPOtherBCBS EFF PRIOR TO 7-1-07
NC7878267OtherAETNA
NC5901473Medicaid