Provider Demographics
NPI:1891841623
Name:THE CHARLOTTE-MECKLENBURG HOSPITAL AUTHORITY
Entity Type:Organization
Organization Name:THE CHARLOTTE-MECKLENBURG HOSPITAL AUTHORITY
Other - Org Name:CMC EASTLAND FAMILY PRACTICE
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATORS
Authorized Official - Prefix:MR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMBAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-355-2154
Mailing Address - Street 1:PO BOX 32861
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28232-2861
Mailing Address - Country:US
Mailing Address - Phone:704-512-6438
Mailing Address - Fax:704-512-6485
Practice Address - Street 1:5516 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28212-2708
Practice Address - Country:US
Practice Address - Phone:704-355-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8901771Medicaid
SCNPA589Medicaid
SCNPA589Medicaid