Basic Information
| Provider Information | |||||||||
| NPI: | 1629057294 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MT AIRY OB GYN CENTER, INC | ||||||||
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| OtherOrganizationName: | MT AIRY OB GYN CENTER, INC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 510 S SOUTH ST | ||||||||
| Address2: | |||||||||
| City: | MOUNT AIRY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270304422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367864522 | ||||||||
| FaxNumber: | 3367893025 | ||||||||
| Practice Location | |||||||||
| Address1: | 510 S SOUTH ST | ||||||||
| Address2: | |||||||||
| City: | MOUNT AIRY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270304422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367864522 | ||||||||
| FaxNumber: | 3367893025 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2006 | ||||||||
| LastUpdateDate: | 07/14/2010 | ||||||||
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| AuthorizedOfficialLastName: | GITT | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3367864522 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 200001210578 | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 02242 | 01 | NC | NC BLUE CROSS BLUE SHIELD | OTHER | 8902242 | 05 | NC | MEDICAID | 0361 | 01 | NC | MEDICARE GROUP NUMBER | OTHER |