Provider Demographics
NPI:1740236041
Name:CAROLINAS MEDICAL CENTER-NORTHEAST
Entity Type:Organization
Organization Name:CAROLINAS MEDICAL CENTER-NORTHEAST
Other - Org Name:NORTHEAST NEUROLOGY
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 1:315 MEDICAL PARK DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-2973
Mailing Address - Country:US
Mailing Address - Phone:704-403-1911
Mailing Address - Fax:704-403-1901
Practice Address - Street 1:315 MEDICAL PARK DR
Practice Address - Street 2:SUITE 202
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2973
Practice Address - Country:US
Practice Address - Phone:704-403-1911
Practice Address - Fax:704-403-1901
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:2013-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC566000156023OtherTRICARE STANDARD, NON NWK
NC355573OtherMAMSI
NCCC2854OtherRAILROAD MEDICARE
NC01895OtherBCBS EFF PRIOR TO 7-1-07
NC7901895Medicaid
NC5906955Medicaid
NC019GNOtherBCBS EFF 7-1-07
NC8599OtherPARTNERS MEDICARE CHOICE
NCDF8926OtherRAILROAD MEDICARE PTAN
NCCC2854OtherRAILROAD MEDICARE
NC=========009OtherTRICARE EFFECTIVE 7/1/07
NC019GNOtherBCBS EFF 7-1-07