=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972744266
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WESTERN CAROLINA NEUROLOGY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/16/2009
-----------------------------------------------------
Last Update Date | 03/16/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 709 N JUSTICE ST SUITE D
-----------------------------------------------------
City | HENDERSONVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28791-3454
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-696-8881
-----------------------------------------------------
Fax | 828-696-8874
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 55 MEDICAL PARK DR SUITE 104
-----------------------------------------------------
City | FRANKLIN
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28734-2651
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-696-8881
-----------------------------------------------------
Fax | 828-696-8874
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE MBR
-----------------------------------------------------
Name | DR. MARK ALON MANDELBAUM
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 828-636-8881
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | 200601663
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------