| NPI | 1053626879 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | WENDY CARSON Manager, Payer Enrollment 234-312-5691 |
| Organization Subpart ? | No |
| Primary Taxonomy | 207RG0300X Internal Medicine Geriatric Medicine |
| Additional Taxonomies | 207Q00000X Family Medicine |
| 207R00000X Internal Medicine | |
| Enumeration Date | 2010-08-17 |
| Last Update Date | 2024-08-14 |