Active NPI
Carolinas Physicians Network Inc.
- Family Medicine Physician
- Matthews, NC
National Provider Identifier
1215125919
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Medicine Physician
- Legal business name
- CAROLINAS PHYSICIANS NETWORK INC.
- Doing business as
- Pine Lake Family Medicine
- Practice address
- 4105 Matthews Mint Hill Rd
Matthews, NC 28105-3633 - Phone
- (704) 545-4609
- Fax
- (704) 545-4798
- NPI assigned
- Oct 9, 2007
- Organization subpart
- Yes
- Parent organization
- CAROLINAS PHYSICIANS NETWORK INC
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Mr. Daniel L. Wiens
- Title
- Senior Vice President of Operations
- Phone
- (704) 355-0648
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | Primary |
Addresses
Primary practice location
4105 Matthews Mint Hill Rd
Matthews, NC 28105-3633
Mailing address
PO Box 601949
Charlotte, NC 28260-1949
Phone (704) 545-4609
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 5908365 | Medicaid | NC |
Other names 1
- Pine Lake Family Medicine
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in NC
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20040115000819 | NC | Part B Supplier - Clinic/Group Practice | 3375449655 |
Receives reassigned benefits from 2,518 practitioners This NPI is an additional NPI on the enrollment |
National Provider Directory
National Provider Directory- Part of
- Cotswold Urgent Care
Member of 19
Organizations this organization is a member of, according to the National Provider Directory.
-
- Hematology & Oncology Physician
- Charlotte, NC
- NPI 1245561554
Member Of
-
- Family Medicine Physician
- Huntersville, NC
- NPI 1508892746
Member Of
-
- Durable Medical Equipment & Medical Supplies
- Charlotte, NC
- NPI 1477879260
Member Of
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1191888000000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1292976000000",
"number": "1215125919",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 601949",
"city": "CHARLOTTE",
"state": "NC",
"postal_code": "282601949",
"telephone_number": "704-545-4609",
"fax_number": "704-545-4798"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4105 MATTHEWS MINT HILL RD",
"city": "MATTHEWS",
"state": "NC",
"postal_code": "281053633",
"telephone_number": "704-545-4609",
"fax_number": "704-545-4798"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "CAROLINAS PHYSICIANS NETWORK INC.",
"organizational_subpart": "YES",
"parent_organization_legal_business_name": "CAROLINAS PHYSICIANS NETWORK INC",
"enumeration_date": "2007-10-09",
"last_updated": "2010-12-22",
"status": "A",
"authorized_official_last_name": "WIENS",
"authorized_official_first_name": "DANIEL",
"authorized_official_middle_name": "L.",
"authorized_official_title_or_position": "SENIOR VICE PRESIDENT OF OPERATIONS",
"authorized_official_telephone_number": "704-355-0648",
"authorized_official_name_prefix": "Mr."
},
"taxonomies": [
{
"code": "207Q00000X",
"taxonomy_group": "193400000X SINGLE SPECIALTY GROUP",
"desc": "Family Medicine",
"state": null,
"license": null,
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "5908365",
"state": "NC"
}
],
"endpoints": [],
"other_names": [
{
"organization_name": "Pine Lake Family Medicine",
"code": "3",
"type": "Doing Business As"
}
]
}Other providers in Matthews, NC
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 22, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.