1922280700 NPI number — AFFILIATED MEDICAL GROUP, PLLC

Table of content: (NPI 1922280700)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922280700 NPI number — AFFILIATED MEDICAL GROUP, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AFFILIATED MEDICAL GROUP, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1922280700
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/17/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 12459
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28546-2459
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-939-0724
Provider Business Mailing Address Fax Number:
910-333-9145

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
39 OFFICE PARK DR STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28546-3220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-939-0724
Provider Business Practice Location Address Fax Number:
910-333-9145
Provider Enumeration Date:
12/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
AHLBERG
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
JOSEPH
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
910-939-0724

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LP0808X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5908381 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com