Provider Demographics
NPI:1790762284
Name:CHARLOTTE PRIMARY CARE, PA
Entity Type:Organization
Organization Name:CHARLOTTE PRIMARY CARE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:TAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-342-8115
Mailing Address - Street 1:1918 RANDOLPH RD
Mailing Address - Street 2:SUITE 440
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28207-1100
Mailing Address - Country:US
Mailing Address - Phone:704-342-8115
Mailing Address - Fax:704-344-2691
Practice Address - Street 1:1918 RANDOLPH RD
Practice Address - Street 2:SUITE 440
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1100
Practice Address - Country:US
Practice Address - Phone:704-342-8115
Practice Address - Fax:704-344-2691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-27
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102928207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC011Y5OtherBCBSNC PROVIDER ID#
NC011Y5OtherBCBSNC PROVIDER ID#