Healthcare Provider Details

I. General information

NPI: 1972590685
Provider Name (Legal Business Name): SUSAN BIGNALL OWENSBY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 07/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 PARK ST SUITE 500
BELMONT NC
28012-5205
US

IV. Provider business mailing address

209 PARK ST SUITE 500
BELMONT NC
28012-5205
US

V. Phone/Fax

Practice location:
  • Phone: 704-829-0025
  • Fax: 704-829-0031
Mailing address:
  • Phone: 704-829-0025
  • Fax: 704-829-0031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number9601426
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: