Provider Demographics
NPI:1588755946
Name:CAROLINA PHYSICAL MEDICINE & REHABILITATION, PC
Entity type:Organization
Organization Name:CAROLINA PHYSICAL MEDICINE & REHABILITATION, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-869-6699
Mailing Address - Street 1:1307 UNION RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-5562
Mailing Address - Country:US
Mailing Address - Phone:704-869-6699
Mailing Address - Fax:704-861-1996
Practice Address - Street 1:1307 UNION RD
Practice Address - Street 2:SUITE 105
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-5562
Practice Address - Country:US
Practice Address - Phone:704-869-6699
Practice Address - Fax:704-861-1996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC23802208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCU68511Medicare UPIN
NCC86970Medicare UPIN