Provider Demographics
NPI:1710202163
Name:MECKLENBURG MEDICAL GROUP
Entity Type:Organization
Organization Name:MECKLENBURG MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
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 60063
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0063
Mailing Address - Country:US
Mailing Address - Phone:704-302-8500
Mailing Address - Fax:704-302-8501
Practice Address - Street 1:332 SAM NEWELL RD
Practice Address - Street 2:SUITE 2000
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-6566
Practice Address - Country:US
Practice Address - Phone:704-302-8500
Practice Address - Fax:704-302-8501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-29
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty