Provider Demographics
NPI:1992735989
Name:PAGELAND FAMILY MEDICINE
Entity type:Organization
Organization Name:PAGELAND FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:WIENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-355-0648
Mailing Address - Street 1:5000 AIRPORT CENTER PKWY STE A
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-5899
Mailing Address - Country:US
Mailing Address - Phone:704-512-4116
Mailing Address - Fax:704-371-7284
Practice Address - Street 1:301 N VAN LINGLE MUNGO BLVD
Practice Address - Street 2:
Practice Address - City:PAGELAND
Practice Address - State:SC
Practice Address - Zip Code:29728
Practice Address - Country:US
Practice Address - Phone:843-672-6127
Practice Address - Fax:843-672-5748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP1123Medicaid
SCGP1123Medicaid