Organization
NMG AFFILIATE PRACTICE I, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
GEOFFREY K. GARDNER (VP OF FINANCE)
(704) 384-9094
Entity
Organization
Contact information
Practice address
1918 RANDOLPH RD, SUITE 175, CHARLOTTE, NC 28207-1100
(704) 316-1050
(704) 316-1051
Mailing address
PO BOX 60447, CHARLOTTE, NC 28260-0447
(704) 316-1050
(704) 316-1051
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
—
—
207Q00000X
Family Medicine Physician
—
—
261QU0200X
Urgent Care Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
011A9
BCBS NC
NC
05
—
89011A9
—
NC
05
—
NPA901
—
SC
Enumeration date
05/11/2006
Last updated
05/04/2011
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