=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336551365
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SARAH ROSE MANGUM NEEDHAM M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2014
-----------------------------------------------------
Last Update Date | 05/26/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 709 CHESAPEAKE PL
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27858-6236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-227-3191
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 709 CHESAPEAKE PL
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27858-6236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-227-3191
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 36386
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------