Healthcare Provider Details

I. General information

NPI: 1730579848
Provider Name (Legal Business Name): REJUVENATION MD, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2015
Last Update Date: 04/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 N FAYETTEVILLE ST SUITE 301
ASHEBORO NC
27203-4670
US

IV. Provider business mailing address

610 N FAYETTEVILLE ST SUITE 301
ASHEBORO NC
27203-4670
US

V. Phone/Fax

Practice location:
  • Phone: 336-633-4034
  • Fax: 336-633-4069
Mailing address:
  • Phone: 336-633-4034
  • Fax: 336-633-4069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number9501252
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number200400470
License Number StateNC

VIII. Authorized Official

Name: UMBREEN CHAUDHARY
Title or Position: OWNER
Credential: MD
Phone: 336-633-4034