Healthcare Provider Details

I. General information

NPI: 1689077539
Provider Name (Legal Business Name): NMG AFFILATE PRACTICE I LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2014
Last Update Date: 05/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 S VAN BUREN RD
EDEN NC
27288-5019
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 336-623-9713
  • Fax: 336-623-1031
Mailing address:
  • Phone: 704-384-7840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. GEOFFREY KEITH GARDNER
Title or Position: VP FINANCE
Credential:
Phone: 704-384-7603