=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356665152
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAPE FEAR VALLEY HEALTH SYSTEM SPECIALTY GROUP, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2010
-----------------------------------------------------
Last Update Date | 07/14/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 104 W SOUTHERN AVE
-----------------------------------------------------
City | RAEFORD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28376-3218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-615-3140
-----------------------------------------------------
Fax | 910-486-2169
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 40908
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28309-0908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-615-6448
-----------------------------------------------------
Fax | 910-615-5070
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. MICHAEL NAGOWSKI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 910-615-6700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | H0213
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------