=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457413999
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FIRST CHOICE MEDICAL GROUP PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/14/2006
-----------------------------------------------------
Last Update Date | 09/05/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 921 E BROAD AVE
-----------------------------------------------------
City | ROCKINGHAM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28379-4338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-895-6042
-----------------------------------------------------
Fax | 910-895-3199
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 921 E BROAD AVE
-----------------------------------------------------
City | ROCKINGHAM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28379-4338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-895-6042
-----------------------------------------------------
Fax | 910-895-3199
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | LARRY E STOGNER
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 910-895-6042
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 1885
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 1825
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 26678
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 26479
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------