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General NPI Number Information
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NPI Number | 1689077539
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Entity Type | Organization
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Legal Business Name | NMG AFFILATE PRACTICE I LLC
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Dates
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Enumeration Date | 10/07/2014
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Last Update Date | 05/14/2015
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Provider Practice Location Address
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Address Line | 516 S VAN BUREN RD
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City | EDEN
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State | NC
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Zip | 27288-5019
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Country | US
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Telephone | 336-623-9713
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Fax | 336-623-1031
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Provider Business Mailing Address
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Address Line | PO BOX 60447
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City | CHARLOTTE
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State | NC
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Zip | 28260-0447
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Country | US
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Telephone | 704-384-7840
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Fax |
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Authorized Official
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Title or Position | VP FINANCE
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Name | MR. GEOFFREY KEITH GARDNER
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Credential |
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Telephone | 704-384-7603
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RX0202X
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Taxonomy Name | Medical Oncology Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207VX0201X
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Taxonomy Name | Gynecologic Oncology Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207RH0003X
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Taxonomy Name | Hematology & Oncology Physician
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License Number |
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License Number State |
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