Healthcare Provider Details

I. General information

NPI: 1396738167
Provider Name (Legal Business Name): ELIZABETH BUMGARNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 02/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14214 BALLANTYNE LAKE RD SUITE 300
CHARLOTTE NC
28277-3372
US

IV. Provider business mailing address

14214 BALLANTYNE LAKE RD
CHARLOTTE NC
28277-3372
US

V. Phone/Fax

Practice location:
  • Phone: 704-667-2600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2010-01070
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: