Healthcare Provider Details

I. General information

NPI: 1043610587
Provider Name (Legal Business Name): CENTRAL CAROLINA OB/GYN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2014
Last Update Date: 08/12/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 NORTHLINE AVE SUITE 130
GREENSBORO NC
27408-7616
US

IV. Provider business mailing address

1501 YAMATO RD SUITE 200 WEST
BOCA RATON FL
33431-4438
US

V. Phone/Fax

Practice location:
  • Phone: 336-286-6565
  • Fax: 336-286-6566
Mailing address:
  • Phone: 561-300-2410
  • Fax: 561-953-4146

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: MS. KATHRYN GARRETT
Title or Position: DIRECTOR MANAGED CARE
Credential:
Phone: 561-300-2410