Healthcare Provider Details

I. General information

NPI: 1487218871
Provider Name (Legal Business Name): NMG AFFILIATE PRACTICE I, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2019
Last Update Date: 05/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 MORAVIAN WAY DR
WINSTON SALEM NC
27106-3216
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 336-856-0701
  • Fax: 336-856-2804
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: SHALA DAVIS
Title or Position: RCS MANAGER
Credential:
Phone: 704-316-7845