Provider Demographics
NPI:1811953995
Name:CAROLINA HEART PA
Entity type:Organization
Organization Name:CAROLINA HEART PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:B
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:252-757-1000
Mailing Address - Street 1:804 JOHNS HOPKINS DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-7222
Mailing Address - Country:US
Mailing Address - Phone:252-757-1000
Mailing Address - Fax:252-757-3045
Practice Address - Street 1:804 JOHNS HOPKINS DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-7222
Practice Address - Country:US
Practice Address - Phone:252-757-1000
Practice Address - Fax:252-757-3045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CK0208OtherRR MEDICARE GROUP NUMBER
NC890176AMedicaid
NC0176AOtherGROUP NUMBER
CK0208OtherRR MEDICARE GROUP NUMBER