Provider Demographics
NPI:1982972501
Name:CAROLINAS PHYSICIANS NETWORK INC.
Entity Type:Organization
Organization Name:CAROLINAS PHYSICIANS NETWORK INC.
Other - Org Name:RUTHERFORD PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VICE PRESIDENT OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WIENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-355-0648
Mailing Address - Street 1:PO BOX 602148
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2148
Mailing Address - Country:US
Mailing Address - Phone:828-245-4061
Mailing Address - Fax:828-245-4062
Practice Address - Street 1:1178 OLD CAROLEEN ROAD
Practice Address - Street 2:
Practice Address - City:FOREST CITY
Practice Address - State:NC
Practice Address - Zip Code:28043-3710
Practice Address - Country:US
Practice Address - Phone:828-245-4061
Practice Address - Fax:828-245-4062
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CAROLINAS PHYSICIANS NETWORK INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-12-09
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5919056Medicaid