Provider Demographics
NPI:1144524190
Name:SOUTH CHARLOTTE GENERAL AND VASCULAR SURGERY PLLC
Entity type:Organization
Organization Name:SOUTH CHARLOTTE GENERAL AND VASCULAR SURGERY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL AND VASCULAR SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:NELSON
Authorized Official - Last Name:ANTEZANA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-412-5126
Mailing Address - Street 1:13430 HOOVER CREEK BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28273-0054
Mailing Address - Country:US
Mailing Address - Phone:704-910-8380
Mailing Address - Fax:704-710-8045
Practice Address - Street 1:13430 HOOVER CREEK BLVD STE 200
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273-0054
Practice Address - Country:US
Practice Address - Phone:704-910-8380
Practice Address - Fax:704-710-8045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-05
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2009-00158208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC59-13992Medicaid
NC59-13992Medicaid