MEDICARE: CAPE FEAR VALLEY HEALTH SYSTEM SPECIALTY GROUP, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1104344183
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAPE FEAR VALLEY HEALTH SYSTEM SPECIALTY GROUP, LLC

Provider Business Mailing Address
First Line	:	PO BOX 40908
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28309-0908
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	588 BAILEY RD STE K
Second Line	:
City	:	LUMBERTON
State	:	NC
Zip	:	28358-2470
Country	:	US
Telephone Number	:	910-615-1888
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MICHAEL NAGOWSKI
Credential	:
Telephone Number	:	910-615-6700

Provider Enumeration Date	:	08/30/2017
Last Update Date	:	09/01/2017

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