Provider Demographics
NPI:1972806321
Name:CMC-NORTHEAST, INC.
Entity Type:Organization
Organization Name:CMC-NORTHEAST, INC.
Other - Org Name:CAROLINAS PEDIATRIC NEUROLOGY CARE - CHARLOTTE SPECIALTY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VP
Authorized Official - Prefix:
Authorized Official - First Name:FRIEDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:LOWDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-403-4146
Mailing Address - Street 1:1001 BLYTHE BLVD
Mailing Address - Street 2:SUITE 200 CPNC - CHARLOTTE SPECIALTY CENTER
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-5866
Mailing Address - Country:US
Mailing Address - Phone:704-381-8840
Mailing Address - Fax:704-381-8848
Practice Address - Street 1:1001 BLYTHE BLVD
Practice Address - Street 2:SUITE 200 CPNC - CHARLOTTE SPECIALTY CENTER
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5866
Practice Address - Country:US
Practice Address - Phone:704-381-8840
Practice Address - Fax:704-381-8848
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CMC-NORTHEAST, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-12-07
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child NeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5916349Medicaid
SCNPB455Medicaid