MECKLENBURG MEDICAL GROUP

Provider Demographics

• NPI: 1255364535
• Name: MECKLENBURG MEDICAL GROUP
• Entity type: Organization
• Organization Name: MECKLENBURG MEDICAL GROUP
• Authorized Official - Title/Position: SENIOR VICE PRESIDENT
• Authorized Official - First Name: DANIEL
• Authorized Official - Middle Name: L
• Authorized Official - Last Name: WIENS
• Authorized Official - Phone: 704-355-0648
• Mailing Address - Street 1: PO BOX 601643
• Mailing Address - City: CHARLOTTE
• Mailing Address - State: NC
• Mailing Address - Zip Code: 28260-1643
• Mailing Address - Country: US
• Mailing Address - Phone: 704-367-8610
• Mailing Address - Fax: 704-367-6798
• Practice Address - Street 1: 7903 PROVIDENCE RD
• Practice Address - Street 2: SUITE 100
• Practice Address - City: CHARLOTTE
• Practice Address - State: NC
• Practice Address - Zip Code: 28277-9720
• Practice Address - Country: US
• Practice Address - Phone: 704-367-8610
• Practice Address - Fax: 704-367-6798
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2006-07-09
• Last Update Date: 2013-03-06

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	207R00000X	Allopathic & Osteopathic Physicians	Internal Medicine		Group - Multi-Specialty
No	207N00000X	Allopathic & Osteopathic Physicians	Dermatology		Group - Multi-Specialty
No	207RC0000X	Allopathic & Osteopathic Physicians	Internal Medicine	Cardiovascular Disease	Group - Multi-Specialty
No	207RE0101X	Allopathic & Osteopathic Physicians	Internal Medicine	Endocrinology, Diabetes & Metabolism	Group - Multi-Specialty
No	207RG0100X	Allopathic & Osteopathic Physicians	Internal Medicine	Gastroenterology	Group - Multi-Specialty
No	207RH0003X	Allopathic & Osteopathic Physicians	Internal Medicine	Hematology & Oncology	Group - Multi-Specialty
No	207RI0200X	Allopathic & Osteopathic Physicians	Internal Medicine	Infectious Disease	Group - Multi-Specialty
No	207RP1001X	Allopathic & Osteopathic Physicians	Internal Medicine	Pulmonary Disease	Group - Multi-Specialty
No	207RR0500X	Allopathic & Osteopathic Physicians	Internal Medicine	Rheumatology	Group - Multi-Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
SC	E08621	Medicaid
NC	5902311	Medicaid
NC	89013CO	Medicaid
NC	89013CW	Medicaid
NC	89013CY	Medicaid
NC	5903117	Medicaid
NC	89013AF	Medicaid
NC	5901377	Medicaid
NC	5905557	Medicaid
NC	89015NA	Medicaid
NC	89013PP	Medicaid
NC	89013CX	Medicaid
	2308340	Medicare ID - Type Unspecified	GROUP NUMBER
NC	89013AF	Medicaid
NC	89013CW	Medicaid
NC	89013CX	Medicaid
NC	5165580002	Medicare NSC