Provider Demographics
NPI:1962728394
Name:ATLANTIC MEDICAL GROUP
Entity type:Organization
Organization Name:ATLANTIC MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:IKECHUKWU
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:IBEGBU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-577-3636
Mailing Address - Street 1:4 JOSH COURT
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-5253
Mailing Address - Country:US
Mailing Address - Phone:910-577-3636
Mailing Address - Fax:910-353-5635
Practice Address - Street 1:4 JOSH COURT
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
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:2010-04-09
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200401229207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2039868Medicare UPIN