Healthcare Provider Details

I. General information

NPI: 1992751374
Provider Name (Legal Business Name): NEW HANOVER MEDICAL GROUP PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 11/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1960 S 16TH ST
WILMINGTON NC
28401-6647
US

IV. Provider business mailing address

1960 S 16TH ST
WILMINGTON NC
28401-6647
US

V. Phone/Fax

Practice location:
  • Phone: 910-343-9991
  • Fax:
Mailing address:
  • Phone: 910-343-9991
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number41057
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number41057
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. MARGO J ILLOBRE
Title or Position: BUSINESS OFFICE SUPERVISOR
Credential:
Phone: 910-343-9991