Provider Demographics
NPI:1386602902
Name:CAROLINAS MEDICAL ALLIANCE INC
Entity type:Organization
Organization Name:CAROLINAS MEDICAL ALLIANCE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BREWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-7000
Mailing Address - Street 1:1590 FREEDOM BLVD
Mailing Address - Street 2:STE A
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29505-6071
Mailing Address - Country:US
Mailing Address - Phone:843-679-4214
Mailing Address - Fax:
Practice Address - Street 1:1590 FREEDOM BLVD
Practice Address - Street 2:STE A
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29505-6071
Practice Address - Country:US
Practice Address - Phone:843-679-4214
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC207Q00000X
208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3796Medicaid
SCGP3747Medicaid
SCGP3796Medicaid
SC7809Medicare PIN