Provider Demographics
NPI:1558630483
Name:ATLANTIC MEDICAL GROUP
Entity Type:Organization
Organization Name:ATLANTIC MEDICAL GROUP
Other - Org Name:AMG ENDOSCOPY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:IKECHUKWU
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:IBEGBU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-527-3636
Mailing Address - Street 1:2541 N.QUEEN ST
Mailing Address - Street 2:
Mailing Address - City:KINSTON
Mailing Address - State:NC
Mailing Address - Zip Code:28501-3851
Mailing Address - Country:US
Mailing Address - Phone:252-527-3636
Mailing Address - Fax:252-523-7407
Practice Address - Street 1:2541 N.QUEEN ST
Practice Address - Street 2:
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28501-3851
Practice Address - Country:US
Practice Address - Phone:252-527-3636
Practice Address - Fax:252-523-7407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-21
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200401229207RG0100X
261QA1903X, 261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
No261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5900314Medicaid
NC139K1OtherBCBS
NCI29684Medicare UPIN
NC5900314Medicaid