Healthcare Provider Details

I. General information

NPI: 1639474240
Provider Name (Legal Business Name): NMG AFFILIATE PRACTICE I LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2011
Last Update Date: 06/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

812 WEST STUART DRIVE
GALAX VA
24333-2605
US

IV. Provider business mailing address

PO BOX 602362
CHARLOTTE NC
28260-2362
US

V. Phone/Fax

Practice location:
  • Phone: 276-238-3318
  • Fax: 276-236-4204
Mailing address:
  • Phone: 704-384-7840
  • Fax: 704-384-7830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: GEOFFREY K GARDNER
Title or Position: VP FINANCE
Credential:
Phone: 276-238-3318