Provider Demographics
| NPI: | 1184777617 |
|---|---|
| Name: | CMC-NORTHEAST, INC. |
| Entity type: | Organization |
| Organization Name: | CMC-NORTHEAST, INC. |
| Other - Org Name: | <UNAVAIL> |
| Other - Org Type: | |
| Authorized Official - Title/Position: | VP PHYSICIAN SERVICES |
| 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: | 105 YADKIN STREET |
| Mailing Address - Street 2: | SUITE 302 |
| Mailing Address - City: | ALBEMARLE |
| Mailing Address - State: | NC |
| Mailing Address - Zip Code: | 28001-3454 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 704-403-1877 |
| Mailing Address - Fax: | 704-986-2150 |
| Practice Address - Street 1: | 105 YADKIN STREET |
| Practice Address - Street 2: | SUITE 302 |
| Practice Address - City: | ALBEMARLE |
| Practice Address - State: | NC |
| Practice Address - Zip Code: | 28001-3454 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 704-403-1877 |
| Practice Address - Fax: | 704-986-2150 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | Yes |
| Parent Organization LBN: | CMC-NORTHEAST, INC. |
| Parent Organization TIN: | <UNAVAIL> |
| Enumeration Date: | 2007-01-19 |
| Last Update Date: | 2012-06-01 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | Group - Single Specialty |
| No | 101Y00000X | Behavioral Health & Social Service Providers | Counselor | Group - Single Specialty | |
| No | 103T00000X | Behavioral Health & Social Service Providers | Psychologist | Group - Single Specialty | |
| No | 103TC2200X | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | Group - Single Specialty |
| No | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Single Specialty |
| No | 106H00000X | Behavioral Health & Social Service Providers | Marriage & Family Therapist | Group - Single Specialty | |
| No | 363LP0808X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psychiatric/Mental Health | Group - Single Specialty |
| No | 101YP2500X | Behavioral Health & Social Service Providers | Counselor | Professional | Group - Single Specialty |
| No | 103TC0700X | Behavioral Health & Social Service Providers | Psychologist | Clinical | Group - Single Specialty |
| No | 103TA0400X | Behavioral Health & Social Service Providers | Psychologist | Addiction (Substance Use Disorder) | Group - Single Specialty |
| No | 103TF0000X | Behavioral Health & Social Service Providers | Psychologist | Family | Group - Single Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| NC | 89015E5 | Medicaid | |
| NC | B948 | Other | PARTNERS MEDICARE CHOICE |
| NC | CC2854 | Other | RAILROAD MEDICARE |
| NC | 019G5 | Other | BCBSNC |
| NC | 355573 | Other | MAMSI |
| NC | 6005328 | Medicaid | |
| NC | DF8926 | Other | RAILROAD MEDICARE PTAN |
| NC | 019G5 | Other | BCBS EFF 7-1-07 |
| NC | 6006579 | Other | MEDICAID, EFF 10/27/2008 |
| NC | 566000156058 | Other | TRICARE STANDARD, NON NWK |
| NC | 5906956 | Medicaid | |
| NC | DF8926 | Other | RAILROAD MEDICARE PTAN |
| NC | DF8926 | Other | RAILROAD MEDICARE PTAN |
| NC | 6005328 | Medicaid |
