Provider Demographics
NPI:1730135047
Name:CAROLINAS MEDICAL CENTER-NORTHEAST
Entity Type:Organization
Organization Name:CAROLINAS MEDICAL CENTER-NORTHEAST
Other - Org Name:CAROLINAS PEDIATRIC NEUROLOGY CARE - CONCORD
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
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-2948
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
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2948
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:CAROLINAS MEDICAL CENTER-NORTHEAST
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-26
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child NeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC019FGOtherBCBS EFF 7-1-07
NC566000156020OtherTRICARE STANDARD, NON NWK
NC5906952Medicaid
NCDF8926OtherRAILROAD MEDICARE PTAN
NC89015Y1Medicaid
NCI912OtherPARTNERS MEDICARE CHOICE
NC355573OtherMAMSI
NC7837542OtherAETNA
SCNPB455Medicaid
NC015Y1OtherBCBS GROUP ID
NC89015Y1Medicaid