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General NPI Number Information
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NPI Number | 1417378779
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Entity Type | Organization
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Legal Business Name | SURGICAL MEDICAL CLINIC
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Dates
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Enumeration Date | 01/03/2014
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Last Update Date | 01/03/2014
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Provider Practice Location Address
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Address Line | 407 EAST FREMONT STREET
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City | BURGAW
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State | NC
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Zip | 28425-0729
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Country | US
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Telephone | 910-259-2161
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Fax | 910-259-7870
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Provider Business Mailing Address
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Address Line | PO BOX 729
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City | BURGAW
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State | NC
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Zip | 28425-0729
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Country | US
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Telephone | 910-259-2161
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Fax | 910-259-7870
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Authorized Official
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Title or Position | OWNER
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Name | DR. NASEEM H NASRALLAH
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Credential | M.D
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Telephone | 910-259-2161
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP2300X
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Taxonomy Name | Primary Care Nurse Practitioner
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License Number | 5005024
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 19763
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License Number State | NC
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