Healthcare Provider Details

I. General information

NPI: 1124020912
Provider Name (Legal Business Name): LAWRENCE MAX LINETT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 03/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2307 N COLLEGE RD
WILMINGTON NC
28405-6427
US

IV. Provider business mailing address

1102 MARKET ST
WILMINGTON NC
28401-4328
US

V. Phone/Fax

Practice location:
  • Phone: 910-392-1488
  • Fax: 910-392-1489
Mailing address:
  • Phone: 910-763-4440
  • Fax: 910-763-4445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number29322
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number29322
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: