Provider Demographics
NPI:1285950790
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 1:8560 COOK ST
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:NC
Mailing Address - Zip Code:28124-7686
Mailing Address - Country:US
Mailing Address - Phone:704-403-1911
Mailing Address - Fax:704-403-1901
Practice Address - Street 1:8560 COOK ST
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:NC
Practice Address - Zip Code:28124-7686
Practice Address - Country:US
Practice Address - Phone:704-403-1911
Practice Address - Fax:704-403-1901
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CMC-NORTHEAST, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-04-09
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC232009OtherMEDICARE PTAN, GROUP
NCDF8926OtherRAILROAD MEDICARE PTAN
NC5915564Medicaid