Basic Information
| Provider Information | |||||||||
| NPI: | 1477526861 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHWEST MEDICAL PARTNERS, P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 280 NORTH POINTE BLVD. | ||||||||
| Address2: | |||||||||
| City: | MT. AIRY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270302267 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367864133 | ||||||||
| FaxNumber: | 3367864338 | ||||||||
| Practice Location | |||||||||
| Address1: | 280 NORTH POINTE BLVD. | ||||||||
| Address2: | |||||||||
| City: | MT. AIRY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270302267 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367864133 | ||||||||
| FaxNumber: | 3367864338 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2006 | ||||||||
| LastUpdateDate: | 02/10/2010 | ||||||||
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| AuthorizedOfficialLastName: | GARDNER | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | N. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3367864133 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | L000989 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | 207Q00000X | 30025 | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8901HN | 05 | NC | MEDICAID | 011NM | 01 | NC | BLUE CROSS BLUE SHIELD OF NC | OTHER |