CMC-NORTHEAST, INC.

Provider Demographics

• NPI: 1750343521
• Name: CMC-NORTHEAST, INC.
• Entity type: Organization
• Organization Name: CMC-NORTHEAST, INC.
• Other - Org Name: <UNAVAIL>
• Authorized Official - Title/Position: VP PHYSICIAN SERVICES
• Authorized Official - First Name: FRIEDA
• Authorized Official - Middle Name: M
• Authorized Official - Last Name: LOWDER
• Authorized Official - Phone: 704-403-4146
• Mailing Address - Street 1: 380 COPPERFIELD BLVD NE
• Mailing Address - Street 2: NORTHEAST PSYCHIATRIC SERVICES
• Mailing Address - City: CONCORD
• Mailing Address - State: NC
• Mailing Address - Zip Code: 28025-2402
• Mailing Address - Country: US
• Mailing Address - Phone: 704-403-1800
• Mailing Address - Fax: 704-403-1836
• Practice Address - Street 1: 380 COPPERFIELD BLVD NE
• Practice Address - Street 2: NORTHEAST PSYCHIATRIC SERVICES
• Practice Address - City: CONCORD
• Practice Address - State: NC
• Practice Address - Zip Code: 28025-2402
• Practice Address - Country: US
• Practice Address - Phone: 704-403-1800
• Practice Address - Fax: 704-403-1836
• EIN: <UNAVAIL>
• Is Organization Subpart?: Yes
• Parent Organization LBN: CMC-NORTHEAST, INC.
• Parent Organization TIN: <UNAVAIL>
• Enumeration Date: 2006-04-05
• Last Update Date: 2012-06-01

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	2084P0800X	Allopathic & Osteopathic Physicians	Psychiatry & Neurology	Psychiatry	Group - Multi-Specialty
No	101Y00000X	Behavioral Health & Social Service Providers	Counselor		Group - Multi-Specialty
No	103T00000X	Behavioral Health & Social Service Providers	Psychologist		Group - Multi-Specialty
No	103TC2200X	Behavioral Health & Social Service Providers	Psychologist	Clinical Child & Adolescent	Group - Multi-Specialty
No	1041C0700X	Behavioral Health & Social Service Providers	Social Worker	Clinical	Group - Multi-Specialty
No	106H00000X	Behavioral Health & Social Service Providers	Marriage & Family Therapist		Group - Multi-Specialty
No	363LP0808X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner	Psychiatric/Mental Health	Group - Multi-Specialty
No	101YP2500X	Behavioral Health & Social Service Providers	Counselor	Professional	Group - Multi-Specialty
No	103TC0700X	Behavioral Health & Social Service Providers	Psychologist	Clinical	Group - Multi-Specialty
No	103TA0400X	Behavioral Health & Social Service Providers	Psychologist	Addiction (Substance Use Disorder)	Group - Multi-Specialty
No	103TF0000X	Behavioral Health & Social Service Providers	Psychologist	Family	Group - Multi-Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
NC	019G5	Other	BCBSNC
NC	355573	Other	MAMSI
NC	566000156021	Other	TRICARE STANDARD, NON NWK
NC	B948	Other	PARTNERS MEDICARE CHOICE
NC	019G5	Other	BCBS EFF 7-1-07
NC	5907156	Medicaid
NC	6005328	Medicaid
NC	890240Y	Medicaid
NC	CC2854	Other	RAILROAD MEDICARE
NC	DF8926	Other	RAILROAD MEDICARE PTAN
NC	B948	Other	PARTNERS MEDICARE CHOICE
NC	CC2854	Other	RAILROAD MEDICARE
NC	2325363	Medicare PIN