Healthcare Provider Details

I. General information

NPI: 1144206822
Provider Name (Legal Business Name): BRUNSWICK SURGICAL ASSOCIATES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 DOCTORS CIR SUITE 1
SUPPLY NC
28462-4089
US

IV. Provider business mailing address

6 DOCTORS CIR SUITE 1
SUPPLY NC
28462-4089
US

V. Phone/Fax

Practice location:
  • Phone: 910-575-4606
  • Fax: 910-575-4609
Mailing address:
  • Phone: 910-575-4606
  • Fax: 910-575-4609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number103114
License Number StateNC

VIII. Authorized Official

Name: MARK TILLOTSON
Title or Position: PARTNER
Credential: M.D.
Phone: 910-575-4606