Provider Demographics
NPI:1114391927
Name:ATLANTIC MEDICAL GROUP
Entity type:Organization
Organization Name:ATLANTIC MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIETITIAN AND FITNESS COACH
Authorized Official - Prefix:MS
Authorized Official - First Name:NATALIE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:856-912-0032
Mailing Address - Street 1:804 EDGEMOOR ROAD
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08034
Mailing Address - Country:US
Mailing Address - Phone:856-912-0032
Mailing Address - Fax:
Practice Address - Street 1:4 JOSH COURT
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE, NC
Practice Address - State:NC
Practice Address - Zip Code:28546-5253
Practice Address - Country:US
Practice Address - Phone:910-577-3636
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-17
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ86008839133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty