Provider Demographics
NPI:1912299413
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:SENIOR VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:FORD
Authorized Official - Last Name:LAYMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-631-0002
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:704-381-3510
Mailing Address - Fax:704-540-3668
Practice Address - Street 1:704 GOLD HILL RD
Practice Address - Street 2:SUITE 203
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29715-8906
Practice Address - Country:US
Practice Address - Phone:704-381-3510
Practice Address - Fax:704-540-3668
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CAROLINAS PHYSICIANS NETWORK INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-05-03
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric UrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5917377Medicaid
SCNPB228Medicaid