Healthcare Provider Details

I. General information

NPI: 1790003580
Provider Name (Legal Business Name): EASTOVER UNIVERSITY OBSTETRICS & GYNECOLOGY ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2010
Last Update Date: 03/09/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5727 PROSPERITY CROSSING DR STE 2100
CHARLOTTE NC
28269-2206
US

IV. Provider business mailing address

PO BOX 19305
CHARLOTTE NC
28219-9305
US

V. Phone/Fax

Practice location:
  • Phone: 704-863-9800
  • Fax:
Mailing address:
  • Phone: 704-631-0002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: SCOTT RISSMILLER
Title or Position: ENTERPRISE EVP
Credential:
Phone: 704-355-8675