Provider Demographics
NPI:1689613754
Name:CAROLINAS MEDICAL CENTER-NORTHEAST
Entity Type:Organization
Organization Name:CAROLINAS MEDICAL CENTER-NORTHEAST
Other - Org Name:OCCUPATIONAL MEDICINE SERVICES
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 1:1090 NORTHEAST GATEWAY COURT NE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-2440
Mailing Address - Country:US
Mailing Address - Phone:704-403-9000
Mailing Address - Fax:704-403-9001
Practice Address - Street 1:1090 NORTHEAST GATEWAY COURT NE
Practice Address - Street 2:SUITE 201
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2440
Practice Address - Country:US
Practice Address - Phone:704-403-9000
Practice Address - Fax:704-403-9001
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CAROLINAS MEDICAL CENTER-NORTHEAST
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-05
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC566000156060OtherTRICARE STANDARD, NON NWK
NCDF8926OtherRAILROAD MEDICARE PTAN
NCH802OtherPARTNERS MEDICARE CHOICE
NC013NTOtherBCBS GROUP ID
NC355573OtherMAMSI
NCCC2854OtherRAILROAD MEDICARE
NC019FCOtherBCBS EFF 7-1-07
NC=========003OtherTRICARE EFFECTIVE 7/1/07
NC232009Medicare PIN
NC2325363Medicare PIN