MEDICARE: DR. MARIA SOCORRO AMBULO GERONIMO MD

Medicare Provider Information

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RG0300X	Geriatric Medicine (Internal Medicine) Physician	2012-00713	NC
2	207RG0300X	Geriatric Medicine (Internal Medicine) Physician	25MA07879400	NJ
3	207R00000X	Internal Medicine Physician	2012-00713	NC

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	25MA07879400	OTHER	NJ	STATE LICENSE

NPI Number	:	1811097967
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARIA SOCORRO AMBULO GERONIMO MD

Provider Business Mailing Address
First Line	:	5960 FAIRVIEW RD STE 500
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28210-3113
Country	:	US
Telephone Number	:	704-495-6334
Fax Number	:	704-817-7219

Provider Business Practice Location Address
First Line	:	630 MATTHEWS TOWNSHIP PKWY
Second Line	:
City	:	MATTHEWS
State	:	NC
Zip	:	28105-5322
Country	:	US
Telephone Number	:	704-495-6020
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/25/2006
Last Update Date	:	01/24/2023