Organization
MECKLENBURG MEDICAL GROUP
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DANIEL L WIENS (SENIOR VICE PRESIDENT)
(704) 355-0648
Entity
Organization
Contact information
Practice address
7903 PROVIDENCE RD, SUITE 100, CHARLOTTE, NC 28277-9720
(704) 367-8610
(704) 367-6798
Mailing address
PO BOX 601643, CHARLOTTE, NC 28260-1643
(704) 367-8610
(704) 367-6798
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
—
—
207R00000X
Internal Medicine Physician
Primary
—
—
207RC0000X
Cardiovascular Disease Physician
—
—
207RE0101X
Endocrinology, Diabetes & Metabolism Physician
—
—
207RG0100X
Gastroenterology Physician
—
—
207RH0003X
Hematology & Oncology Physician
—
—
207RI0200X
Infectious Disease Physician
—
—
207RP1001X
Pulmonary Disease Physician
—
—
207RR0500X
Rheumatology Physician
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
5901377
—
NC
05
—
5902311
—
NC
05
—
5903117
—
NC
05
—
5905557
—
NC
05
—
89013AF
—
NC
05
—
89013CO
—
NC
05
—
89013CW
—
NC
05
—
89013CX
—
NC
05
—
89013CY
—
NC
05
—
89013PP
—
NC
05
—
89015NA
—
NC
05
—
E08621
—
SC
Enumeration date
07/09/2006
Last updated
03/06/2013
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