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General NPI Number Information
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NPI Number | 1922104066
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Entity Type | Organization
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Legal Business Name | OWEN DRIVE SURGICAL CLINIC, PA
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Dates
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Enumeration Date | 09/16/2006
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Last Update Date | 10/07/2009
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Provider Practice Location Address
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Address Line | 1617 OWEN DR
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City | FAYETTEVILLE
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State | NC
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Zip | 28304-3425
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Country | US
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Telephone | 910-484-0101
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Fax | 910-484-2563
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Provider Business Mailing Address
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Address Line | PO BOX 1615
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City | ETOWAH
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State | NC
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Zip | 28729-1615
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Country | US
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Telephone | 910-484-0101
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Fax | 910-484-2563
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Authorized Official
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Title or Position | PRESIDENT
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Name | DEBI CHAUDHURI
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Credential | MD
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Telephone | 910-484-0101
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number |
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License Number State |
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