Provider Demographics
NPI:1265757942
Name:GHNEIM, MIRA H (MD)
Entity type:Individual
Prefix:
First Name:MIRA
Middle Name:H
Last Name:GHNEIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 751069
Mailing Address - Street 2:ECU PHYSICIANS
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:517 MOYE BLVD
Practice Address - Street 2:ECU PHYSICIANS TRAUMA SURGERY
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-2849
Practice Address - Country:US
Practice Address - Phone:252-847-4299
Practice Address - Fax:252-847-8208
Is Sole Proprietor?:No
Enumeration Date:2010-04-06
Last Update Date:2016-11-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXBP1-0037256208600000X
NC2016-00821208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC19KJAOtherBCBS OF NC
NC1265757942Medicaid
NC1265757942Medicaid