Provider Demographics
NPI:1841513363
Name:CMC - NORTHEAST, INC.
Entity type:Organization
Organization Name:CMC - NORTHEAST, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR VP
Authorized Official - Prefix:
Authorized Official - First Name:FRIEDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:LOWDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-403-4146
Mailing Address - Street 1:1001 BLYTHE BLVD
Mailing Address - Street 2:SUITE 200D NORTHEAST PEDIATRIC PULMONLOGY-CHARLOTTE
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-5866
Mailing Address - Country:US
Mailing Address - Phone:704-403-2660
Mailing Address - Fax:704-403-2670
Practice Address - Street 1:1001 BLYTHE BLVD
Practice Address - Street 2:SUITE 200D NORTHEAST PEDIATRIC PULMONLOGY-CHARLOTTE
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5866
Practice Address - Country:US
Practice Address - Phone:704-403-2660
Practice Address - Fax:704-403-2670
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CMC - NORTHEAST, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-03-11
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric PulmonologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5914618Medicaid
SCQPB689Medicaid
NCDF8926OtherRAILROAD MEDICARE PTAN