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2709 Water Ridge Pkwy B5,s500 Charlotte NC 28217-4596 | |
| (704) 446-9173 | |
| Not Available |
| Full Name | |
|---|---|
| Speciality | Family Medicine |
| Location | 2709 Water Ridge Pkwy, Charlotte, North Carolina |
| Authorized Official Name and Position | Daniel L Wiens (SVP/OPERATIONS CHS) |
| Authorized Official Contact | 7043550648 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
Po Box 60099 Charlotte NC 28260-0099 Ph: (704) 677-2650 | 2709 Water Ridge Pkwy B5,s500 Charlotte NC 28217-4596 Ph: (704) 446-9173 |
| NPI Number | 1578939914 |
|---|---|
| Provider Enumeration Date | 08/20/2015 |
| Last Update Date | 08/25/2015 |
| Medicare PECOS PAC ID | 3375449655 |
|---|---|
| Medicare Enrollment ID | O20240723002484 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1578939914 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | (* (Not Available)) | Primary |
| Provider Name | Shree J Shah |
|---|---|
| Provider Type | Practitioner - Diagnostic Radiology |
| Provider Identifiers | NPI Number: 1588688782 PECOS PAC ID: 8729086715 Enrollment ID: I20061130000194 |
| Provider Name | Dennis Burton |
|---|---|
| Provider Type | Practitioner - Diagnostic Radiology |
| Provider Identifiers | NPI Number: 1043298417 PECOS PAC ID: 7416857388 Enrollment ID: I20110406000864 |
| Provider Name | David K Bass |
|---|---|
| Provider Type | Practitioner - Diagnostic Radiology |
| Provider Identifiers | NPI Number: 1225076219 PECOS PAC ID: 8921912411 Enrollment ID: I20190813003160 |
| Provider Name | Feras Jalab |
|---|---|
| Provider Type | Practitioner - Diagnostic Radiology |
| Provider Identifiers | NPI Number: 1104104637 PECOS PAC ID: 5092134361 Enrollment ID: I20220714003596 |
| Provider Name | Bradley Scott Horne |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1295186633 PECOS PAC ID: 6002103272 Enrollment ID: I20240723002816 |
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