# INDIAN TRAIL FAMILY MEDICINE

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1003842782
- **Authorized official:** DANIEL L WIENS (SENIOR VICE PRESIDENT)
- **Authorized official phone:** (704) 355-0648

## Contact information

- **Practice address:** 4503 OLD MONROE RD, INDIAN TRAIL, NC 28079-5309
- **Practice address phone:** (704) 821-6900
- **Practice address fax:** (704) 821-6911
- **Mailing address:** 5000 AIRPORT CENTER PKWY STE A, CHARLOTTE, NC 28208-5899
- **Mailing address phone:** (704) 512-4116
- **Mailing address fax:** (704) 371-7284

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | — | NULL | Yes |
| 207Q00000X | Family Medicine Physician | — | — | Yes |

## Other

- **Enumeration date:** 06/24/2006
- **Last updated:** 02/12/2008

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 7901052 | — | NC |