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General NPI Number Information
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NPI Number | 1144206822
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Entity Type | Organization
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Legal Business Name | BRUNSWICK SURGICAL ASSOCIATES, PLLC
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Dates
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Enumeration Date | 12/15/2005
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 6 DOCTORS CIR SUITE 1
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City | SUPPLY
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State | NC
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Zip | 28462-4089
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Country | US
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Telephone | 910-575-4606
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Fax | 910-575-4609
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Provider Business Mailing Address
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Address Line | 6 DOCTORS CIR SUITE 1
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City | SUPPLY
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State | NC
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Zip | 28462-4089
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Country | US
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Telephone | 910-575-4606
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Fax | 910-575-4609
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Authorized Official
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Title or Position | PARTNER
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Name | MARK TILLOTSON
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Credential | M.D.
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Telephone | 910-575-4606
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2086S0129X
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Taxonomy Name | Vascular Surgery Physician
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License Number | 103114
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License Number State | NC
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