Provider Demographics
NPI:1952477671
Name:UNION PHYSICIANS NETWORK INC
Entity Type:Organization
Organization Name:UNION PHYSICIANS NETWORK INC
Other - Org Name:INDIAN TRAIL PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:MR
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 601892
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1892
Mailing Address - Country:US
Mailing Address - Phone:704-246-2900
Mailing Address - Fax:704-246-2899
Practice Address - Street 1:6030 W HIGHWAY 74
Practice Address - Street 2:SUITE F
Practice Address - City:INDIAN TRAIL
Practice Address - State:NC
Practice Address - Zip Code:28079-3468
Practice Address - Country:US
Practice Address - Phone:704-246-2900
Practice Address - Fax:704-246-2899
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNION PHYSICIANS NETWORK INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-27
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5905684Medicaid