Provider Demographics
NPI:1639153448
Name:VIDANT MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:VIDANT MEDICAL GROUP LLC
Other - Org Name:VIDANT UROLOGY-GREENVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARRILEE
Authorized Official - Middle Name:D
Authorized Official - Last Name:ANDREU-NEEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-816-1137
Mailing Address - Street 1:275 BETHESDA DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-7217
Mailing Address - Country:US
Mailing Address - Phone:252-752-5077
Mailing Address - Fax:252-752-9544
Practice Address - Street 1:275 BETHESDA DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-7217
Practice Address - Country:US
Practice Address - Phone:252-752-5077
Practice Address - Fax:252-752-9544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-05
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8901688Medicaid
NC01688OtherBLUE CROSS BLUE SHIELD
34D0934367OtherCLIA ID
NC8901688Medicaid