Healthcare Provider Details

I. General information

NPI: 1386388874
Provider Name (Legal Business Name): TARHEEL EMERGENCY GROUP, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2022
Last Update Date: 04/21/2022
Certification Date: 04/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 WESTERN BLVD
JACKSONVILLE NC
28546-6338
US

IV. Provider business mailing address

5665 NEW NORTHSIDE DR STE 320
ATLANTA GA
30328-5834
US

V. Phone/Fax

Practice location:
  • Phone: 910-577-2345
  • Fax:
Mailing address:
  • Phone: 770-874-5400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KIM LARSEN
Title or Position: DIRECTOR
Credential:
Phone: 770-874-5400