Provider Demographics
NPI:1134185184
Name:CAROLINA SPINE, PAIN AND REHABILITATION PLLC
Entity type:Organization
Organization Name:CAROLINA SPINE, PAIN AND REHABILITATION PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:HERMAN
Authorized Official - Middle Name:CLARK
Authorized Official - Last Name:GORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-864-3300
Mailing Address - Street 1:PO BOX 550700
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28055-0700
Mailing Address - Country:US
Mailing Address - Phone:704-864-3300
Mailing Address - Fax:704-864-2002
Practice Address - Street 1:900 COX RD
Practice Address - Street 2:STE A
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-3460
Practice Address - Country:US
Practice Address - Phone:704-864-3300
Practice Address - Fax:704-864-2002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5950164Medicaid
SCN00851Medicaid
NC020JAOtherBLUECROSS BLUESHIELD
NC7705149Medicaid
SCN00851Medicaid
NC5950164Medicaid
NC2331982Medicare PIN
NCQ64079Medicare UPIN