Provider Demographics
NPI:1750671723
Name:CAROLINA VASCULAR SPECIALISTS, PA
Entity Type:Organization
Organization Name:CAROLINA VASCULAR SPECIALISTS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:WALLACE
Authorized Official - Middle Name:C
Authorized Official - Last Name:TARRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-799-3939
Mailing Address - Street 1:146 MEDICAL PARK RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-8528
Mailing Address - Country:US
Mailing Address - Phone:704-799-3939
Mailing Address - Fax:704-799-8748
Practice Address - Street 1:146 MEDICAL PARK RD
Practice Address - Street 2:SUITE 102
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-8528
Practice Address - Country:US
Practice Address - Phone:704-799-3939
Practice Address - Fax:704-799-8748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-12
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5917234Medicaid
NC2003788BMedicare PIN