| NPI | 1306105150 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | LORRAINE MCCUNE Credentialing Specialist 567-585-1964 |
| Organization Subpart ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine |
| Additional Taxonomies | 207QS0010X Family Medicine Sports Medicine |
| 207RE0101X Internal Medicine Endocrinology, Diabetes & Metabolism | |
| 2086S0122X Surgery Plastic and Reconstructive Surgery | |
| 261QM1300X Clinic/Center Multi-Specialty | |
| Enumeration Date | 2012-05-15 |
| Last Update Date | 2024-07-11 |