Provider Demographics
NPI:1205801412
Name:CENTRAL CAROLINA NEPHROLOGY PA
Entity type:Organization
Organization Name:CENTRAL CAROLINA NEPHROLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:KENNETH
Authorized Official - Last Name:HALSTENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-786-7770
Mailing Address - Street 1:200 MEDICAL PARK DR
Mailing Address - Street 2:STE 320
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-2982
Mailing Address - Country:US
Mailing Address - Phone:704-786-7770
Mailing Address - Fax:704-788-9351
Practice Address - Street 1:200 MEDICAL PARK DR
Practice Address - Street 2:STE 320
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2982
Practice Address - Country:US
Practice Address - Phone:704-786-7770
Practice Address - Fax:704-788-9351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890213HMedicaid
NC0213HOtherBCBS GROUP #
NC2316655Medicare ID - Type UnspecifiedGROUP #