Provider Demographics
NPI:1336819408
Name:NMG AFFILIATE PRACTICE I, LLC
Entity Type:Organization
Organization Name:NMG AFFILIATE PRACTICE I, LLC
Other - Org Name:UVA GENERAL SURGERY WOODBRIDGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RCS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHALA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-303-7517
Mailing Address - Street 1:PO BOX 936952
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-6952
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14010 SMOKETOWN RD STE 105
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-4723
Practice Address - Country:US
Practice Address - Phone:703-730-4848
Practice Address - Fax:703-730-7236
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-20
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty