Provider Demographics
NPI:1144206822
Name:BRUNSWICK SURGICAL ASSOCIATES, PLLC
Entity Type:Organization
Organization Name:BRUNSWICK SURGICAL ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:TILLOTSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-575-4606
Mailing Address - Street 1:6 DOCTORS CIR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:SUPPLY
Mailing Address - State:NC
Mailing Address - Zip Code:28462-4089
Mailing Address - Country:US
Mailing Address - Phone:910-575-4606
Mailing Address - Fax:910-575-4609
Practice Address - Street 1:6 DOCTORS CIR
Practice Address - Street 2:SUITE 1
Practice Address - City:SUPPLY
Practice Address - State:NC
Practice Address - Zip Code:28462-4089
Practice Address - Country:US
Practice Address - Phone:910-575-4606
Practice Address - Fax:910-575-4609
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1031142086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89015K7Medicaid
NC89015K7Medicaid