Provider Demographics
NPI:1184929796
Name:NMG AFFILIATE PRACTICE I LLC
Entity type:Organization
Organization Name:NMG AFFILIATE PRACTICE I LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:GEOFFERY
Authorized Official - Middle Name:K
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-719-7892
Mailing Address - Street 1:PO BOX 602362
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2362
Mailing Address - Country:US
Mailing Address - Phone:704-384-7840
Mailing Address - Fax:704-384-7830
Practice Address - Street 1:694 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-3117
Practice Address - Country:US
Practice Address - Phone:336-719-7892
Practice Address - Fax:336-719-7898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-13
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty