| NPI | 1285284091 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | MELISSA REESE Provider Enrollment Officer 855-687-0618 |
| Organization Subpart ? | No |
| Primary Taxonomy | 207R00000X Internal Medicine |
| Additional Taxonomies | 208600000X Surgery |
| Enumeration Date | 2019-09-13 |
| Last Update Date | 2023-02-24 |