Provider Demographics
NPI:1780913921
Name:CHARLOTTE MEDICAL CLINIC
Entity type:Organization
Organization Name:CHARLOTTE MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:
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 601643
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1643
Mailing Address - Country:US
Mailing Address - Phone:704-512-4808
Mailing Address - Fax:704-512-4838
Practice Address - Street 1:10545 BLAIR ROAD
Practice Address - Street 2:SUITE 2100
Practice Address - City:MINT HILL
Practice Address - State:NC
Practice Address - Zip Code:28227-2804
Practice Address - Country:US
Practice Address - Phone:704-863-9500
Practice Address - Fax:704-863-9501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-17
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5908921Medicaid
NC2308414Medicare PIN