Provider Demographics
NPI:1538199567
Name:CAROLINA PHYSICIANS GROUP, PC
Entity type:Organization
Organization Name:CAROLINA PHYSICIANS GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:FERNANDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-378-4357
Mailing Address - Street 1:7615 COLONY RD STE 115
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-5001
Mailing Address - Country:US
Mailing Address - Phone:704-378-4357
Mailing Address - Fax:704-626-6824
Practice Address - Street 1:7615 COLONY RD STE 115
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-5001
Practice Address - Country:US
Practice Address - Phone:704-626-6812
Practice Address - Fax:704-626-6824
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0099-01172207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891235UMedicaid
NC8912356Medicaid
2325217Medicare PIN