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General NPI Number Information
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NPI Number | 1639153448
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Entity Type | Organization
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Legal Business Name | VIDANT MEDICAL GROUP LLC
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Dates
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Enumeration Date | 12/05/2005
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Last Update Date | 09/11/2019
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Provider Practice Location Address
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Address Line | 275 BETHESDA DR
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City | GREENVILLE
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State | NC
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Zip | 27834-7217
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Country | US
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Telephone | 252-752-5077
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Fax | 252-752-9544
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Provider Business Mailing Address
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Address Line | 275 BETHESDA DR
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City | GREENVILLE
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State | NC
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Zip | 27834-7217
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Country | US
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Telephone | 252-752-5077
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Fax | 252-752-9544
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Authorized Official
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Title or Position | PRACTICE ADMINISTRATOR
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Name | MRS. CARRILEE D ANDREU-NEEL
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Credential |
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Telephone | 252-816-1137
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number |
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License Number State | NC
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