=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669825105
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NMG AFFILIATE PRACTICE I, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2016
-----------------------------------------------------
Last Update Date | 07/20/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15195 HEATHCOTE BLVD SUITE 338
-----------------------------------------------------
City | HAYMARKET
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20169-6242
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-261-3270
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 60447
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28260-0447
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-384-7680
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP OF FINANCE
-----------------------------------------------------
Name | GEOFFREY K. GARDNER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 704-384-7680
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------