Provider Demographics
NPI:1922449263
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 OB/GYN
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:571-261-3529
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:703-361-3551
Mailing Address - Fax:703-365-7702
Practice Address - Street 1:25055 RIDING PLZ
Practice Address - Street 2:SUITE 230
Practice Address - City:SOUTH RIDING
Practice Address - State:VA
Practice Address - Zip Code:20152-5917
Practice Address - Country:US
Practice Address - Phone:703-361-3551
Practice Address - Fax:703-365-7702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-16
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1922449263Medicaid
VA1922449263Medicaid