Healthcare Provider Details

I. General information

NPI: 1417049867
Provider Name (Legal Business Name): FIFTH AVENUE INTERNAL MEDICINE AND GERIATRICS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

724 FIFTH AVENUE WEST
HENDERSONVILLE NC
28739
US

IV. Provider business mailing address

724 FIFTH AVENUE WEST
HENDERSONVILLE NC
28739
US

V. Phone/Fax

Practice location:
  • Phone: 828-693-6566
  • Fax: 828-693-6765
Mailing address:
  • Phone: 828-693-6566
  • Fax: 828-693-6765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number103068
License Number StateNC

VIII. Authorized Official

Name: MR. PHILLIP M KLEIN
Title or Position: OFFICE MANAGER
Credential:
Phone: 828-693-6566