Provider Demographics
NPI:1063403160
Name:CHARLENE LYDIA BLAINE
Entity type:Organization
Organization Name:CHARLENE LYDIA BLAINE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHARLENE
Authorized Official - Middle Name:LYDIA
Authorized Official - Last Name:BLAINE
Authorized Official - Suffix:
Authorized Official - Credentials:CRT, RCP
Authorized Official - Phone:919-359-9920
Mailing Address - Street 1:11048 CLEVELAND ROAD
Mailing Address - Street 2:SUITE 101-102
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529
Mailing Address - Country:US
Mailing Address - Phone:919-359-9920
Mailing Address - Fax:919-359-2520
Practice Address - Street 1:11048 CLEVELAND ROAD
Practice Address - Street 2:SUITE 101-102
Practice Address - City:GARNER
Practice Address - State:NC
Practice Address - Zip Code:27529
Practice Address - Country:US
Practice Address - Phone:919-359-9920
Practice Address - Fax:919-359-2520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-31
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9500533207RS0012X, 207RP1001X
NCA-41252278P1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Single Specialty
No2278P1004XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedPulmonary DiagnosticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC017PYOtherBCBSNC
NC37119OtherPARTNERS
NC429202OtherWELLPATH
NC3500316OtherUNITED HEALTHCARE
NC5902258Medicaid
NC=========OtherWEBMD/ENVOY
NC37119OtherPARTNERS
NC=========OtherTRICARE/CHAMPUS
NC=========OtherAETNA
NC5902258Medicaid