Healthcare Provider Details

I. General information

NPI: 1922449263
Provider Name (Legal Business Name): NMG AFFILIATE PRACTICE I, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2013
Last Update Date: 04/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25055 RIDING PLZ SUITE 230
SOUTH RIDING VA
20152-5917
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 703-361-3551
  • Fax: 703-365-7702
Mailing address:
  • Phone: 703-361-3551
  • Fax: 703-365-7702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: GEOFFREY K GARDNER
Title or Position: VP OF FINANCE
Credential:
Phone: 571-261-3529