Healthcare Provider Details

I. General information

NPI: 1871569046
Provider Name (Legal Business Name): JOHN H MYRACLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 12/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 KINDERTON BLVD
ADVANCE NC
27006-7302
US

IV. Provider business mailing address

1701 WESTCHESTER DRIVE SUITE 850
HIGH POINT NC
27262-7254
US

V. Phone/Fax

Practice location:
  • Phone: 336-998-9742
  • Fax: 336-998-9410
Mailing address:
  • Phone: 336-802-2536
  • Fax: 336-802-2534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number22603
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier8961727
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: