Basic Information
| Provider Information | |||||||||
| NPI: | 1992123772 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCMUNN | ||||||||
| FirstName: | JEDEDIAH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 751803 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282751803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362772000 | ||||||||
| FaxNumber: | 3362772050 | ||||||||
| Practice Location | |||||||||
| Address1: | 186 KIMEL PARK DR | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271036946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362772000 | ||||||||
| FaxNumber: | 3362772050 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2014 | ||||||||
| LastUpdateDate: | 07/14/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 0101268626 | VA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | 0101268626 | VA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 2022-00662 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 1992123772 | 05 | VA | MEDICAID |