Healthcare Provider Details

I. General information

NPI: 1154701878
Provider Name (Legal Business Name): NMG AFFILIATE PRACTICE I, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2015
Last Update Date: 06/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8567 SUDLEY RD STE B
MANASSAS VA
20110-3865
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 703-369-5959
  • Fax: 703-369-7473
Mailing address:
  • Phone: 703-369-5959
  • Fax: 703-369-7473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number
License Number State

VIII. Authorized Official

Name: GEOFFERY K GARDNER
Title or Position: VP OF FINANCE
Credential:
Phone: 704-384-7606