Basic Information
| Provider Information | |||||||||
| NPI: | 1184929796 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NMG AFFILIATE PRACTICE I LLC | ||||||||
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| OtherOrganizationName: | NOVANT HEALTH HEART AND VASCULAR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 602362 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282602362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043847840 | ||||||||
| FaxNumber: | 7043847830 | ||||||||
| Practice Location | |||||||||
| Address1: | 694 RIVERSIDE DR | ||||||||
| Address2: | |||||||||
| City: | MOUNT AIRY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270303117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367197892 | ||||||||
| FaxNumber: | 3367197898 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2011 | ||||||||
| LastUpdateDate: | 06/21/2013 | ||||||||
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| AuthorizedOfficialLastName: | GARDNER | ||||||||
| AuthorizedOfficialFirstName: | GEOFFERY | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | VP OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 3367197892 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.