Healthcare Provider Details

I. General information

NPI: 1265895742
Provider Name (Legal Business Name): NMG AFFILIATE PRACTICE I, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2016
Last Update Date: 04/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15195 HEATHCOTE BLVD STE 350
HAYMARKET VA
20169-6242
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 704-316-7585
  • Fax:
Mailing address:
  • Phone: 704-316-7585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: GEOFFREY K GARDNER
Title or Position: VP OF FINANCE
Credential:
Phone: 704-316-7585