Provider Demographics
NPI:1689777245
Name:MID-CAROLINA RADIOLOGY ASSOCIATES P.A.
Entity Type:Organization
Organization Name:MID-CAROLINA RADIOLOGY ASSOCIATES P.A.
Other - Org Name:MID-CAROLINA RADIOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:WITTENBORN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-774-2055
Mailing Address - Street 1:PO BOX 63367
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28263-3367
Mailing Address - Country:US
Mailing Address - Phone:866-759-4524
Mailing Address - Fax:757-512-5025
Practice Address - Street 1:1135 CARTHAGE ST
Practice Address - Street 2:CENTRAL CAROLINA HOSPITAL
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330-4162
Practice Address - Country:US
Practice Address - Phone:919-777-7092
Practice Address - Fax:919-774-2399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7902165Medicaid
NC02165OtherBCBS
NC204240Medicare PIN
NC7902165Medicaid