Provider Demographics
NPI:1669825105
Name:NMG AFFILIATE PRACTICE I, LLC
Entity Type:Organization
Organization Name:NMG AFFILIATE PRACTICE I, LLC
Other - Org Name:NOVANT HEALTH UVA HEALTH SYSTEM LAKE MANASSAS OBGYN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:GEOFFREY
Authorized Official - Middle Name:K
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-384-7680
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-7680
Mailing Address - Fax:
Practice Address - Street 1:15195 HEATHCOTE BLVD
Practice Address - Street 2:SUITE 338
Practice Address - City:HAYMARKET
Practice Address - State:VA
Practice Address - Zip Code:20169-6242
Practice Address - Country:US
Practice Address - Phone:571-261-3270
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-20
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty