Provider Demographics
NPI:1831285840
Name:CAROLINA INTERNAL MEDICINE, PA
Entity Type:Organization
Organization Name:CAROLINA INTERNAL MEDICINE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:CERVI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:252-830-2021
Mailing Address - Street 1:2460 EMERALD PL
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-5784
Mailing Address - Country:US
Mailing Address - Phone:252-830-2021
Mailing Address - Fax:252-830-2042
Practice Address - Street 1:2460 EMERALD PL
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-5784
Practice Address - Country:US
Practice Address - Phone:252-830-2021
Practice Address - Fax:252-830-2042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0190MOtherBCBS OF NC
NC77639OtherMEDCOST
NC2599238Medicare ID - Type Unspecified