Provider Demographics
NPI:1386991297
Name:CAROLINAS PHYSICIANS NETWORK INC
Entity type:Organization
Organization Name:CAROLINAS PHYSICIANS NETWORK INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ENTERPRISE EVP
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:RISSMILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-355-8675
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:704-631-0002
Mailing Address - Fax:
Practice Address - Street 1:14214 BALLANTYNE LAKE RD
Practice Address - Street 2:STE 150
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-3372
Practice Address - Country:US
Practice Address - Phone:704-863-4878
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CAROLINAS PHYSICIANS NETWORK INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-08-09
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports MedicineGroup - Multi-Specialty
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1386991297Medicaid
SCNPB635Medicaid
NC5921573Medicaid
NC4843180033Medicare NSC
NC2331634AMedicare PIN