Provider Demographics
NPI:1184799561
Name:UNION PHYSICIANS NETWORK INC
Entity type:Organization
Organization Name:UNION PHYSICIANS NETWORK INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:MR
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 601897
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0628
Mailing Address - Country:US
Mailing Address - Phone:843-672-6127
Mailing Address - Fax:843-672-5748
Practice Address - Street 1:301 N VAN LINGLE MUNGO BLVD.
Practice Address - Street 2:
Practice Address - City:PAGELAND
Practice Address - State:SC
Practice Address - Zip Code:29728-0278
Practice Address - Country:US
Practice Address - Phone:843-672-6127
Practice Address - Fax:843-672-5748
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNION PHYSICIANS NETWORK INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-21
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC332B00000X
207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4568Medicaid
SCDE3288Medicaid
SCDE3288Medicaid