Provider Demographics
NPI:1619124401
Name:CHARLOTTE GASTROENTEROLOGY & HEPATOLOGY, PLLC
Entity type:Organization
Organization Name:CHARLOTTE GASTROENTEROLOGY & HEPATOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFI
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-377-4009
Mailing Address - Street 1:13808 PROFESSIONAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-7948
Mailing Address - Country:US
Mailing Address - Phone:704-377-4009
Mailing Address - Fax:704-375-6970
Practice Address - Street 1:15830 BALLANTYNE MEDICAL PLACE
Practice Address - Street 2:SUITE 175
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-3295
Practice Address - Country:US
Practice Address - Phone:704-377-4009
Practice Address - Fax:704-375-6970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-22
Last Update Date:2025-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3409963Medicaid
NC2381280Medicare PIN