Healthcare Provider Details

I. General information

NPI: 1821112673
Provider Name (Legal Business Name): BRUNSWICK CARDIOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 09/02/2025
Certification Date: 01/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 MEDICAL CAMPUS DR NW STE 203
SUPPLY NC
28462-4094
US

IV. Provider business mailing address

PO BOX 427
SUPPLY NC
28462-0427
US

V. Phone/Fax

Practice location:
  • Phone: 910-755-7192
  • Fax: 910-755-7194
Mailing address:
  • Phone: 910-755-7192
  • Fax: 910-755-7194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number35196
License Number StateNC

VIII. Authorized Official

Name: REBECCA LITTLE
Title or Position: OFFICE ASSISTANT
Credential:
Phone: 910-755-7192