Provider Demographics
NPI:1922038066
Name:CLEVELAND MEDICAL ASSOCIATES
Entity Type:Organization
Organization Name:CLEVELAND MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:WIENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-355-0648
Mailing Address - Street 1:PO BOX 60061
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0061
Mailing Address - Country:US
Mailing Address - Phone:704-734-5129
Mailing Address - Fax:704-730-9536
Practice Address - Street 1:608 W KING ST
Practice Address - Street 2:PROF BUILDING 2
Practice Address - City:KINGS MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:28086-3358
Practice Address - Country:US
Practice Address - Phone:704-734-5129
Practice Address - Fax:704-730-9536
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2009-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89012UPMedicaid
SCNPB013Medicaid
NC89012UPMedicaid