Provider Demographics
NPI:1376647073
Name:LUMBERTON INTERNAL MEDICINE GROUP
Entity Type:Organization
Organization Name:LUMBERTON INTERNAL MEDICINE GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MAC
Authorized Official - Middle Name:ADOLF
Authorized Official - Last Name:MONTILUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-272-8800
Mailing Address - Street 1:4314 LUDGATE ST
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-2461
Mailing Address - Country:US
Mailing Address - Phone:910-272-8800
Mailing Address - Fax:910-272-0508
Practice Address - Street 1:4314 LUDGATE ST
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-2461
Practice Address - Country:US
Practice Address - Phone:910-272-8800
Practice Address - Fax:910-272-0508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9701503174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCG59193Medicare UPIN