Provider Demographics
NPI:1992751374
Name:NEW HANOVER MEDICAL GROUP PA
Entity type:Organization
Organization Name:NEW HANOVER MEDICAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE SUPERVISOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARGO
Authorized Official - Middle Name:J
Authorized Official - Last Name:ILLOBRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-343-9991
Mailing Address - Street 1:1960 S 16TH ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-6647
Mailing Address - Country:US
Mailing Address - Phone:910-343-9991
Mailing Address - Fax:
Practice Address - Street 1:1960 S 16TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-6647
Practice Address - Country:US
Practice Address - Phone:910-343-9991
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC41057207Q00000X, 207R00000X
2085B0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890218JMedicaid
NC230499BMedicare PIN
NC1022110001Medicare NSC
NC230499AMedicare PIN
NC230499Medicare PIN