Basic Information
| Provider Information | |||||||||
| NPI: | 1740273242 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TOWARNICKY | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 896206 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282896206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2526331010 | ||||||||
| FaxNumber: | 2522243071 | ||||||||
| Practice Location | |||||||||
| Address1: | 4275 WESTERN BLVD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285461100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9109383099 | ||||||||
| FaxNumber: | 9109383243 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2005 | ||||||||
| LastUpdateDate: | 03/17/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 3598 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 83651 | 01 | NC | BLUE CROSS | OTHER | 7983651 | 05 | NC | MEDICAID | 211019D | 01 | NC | MEDICARE PTAN | OTHER |