Basic Information
| Provider Information | |||||||||
| NPI: | 1053369504 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FORSYTH MEDICAL GROUP, LLC | ||||||||
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| OtherOrganizationName: | FAMILY FOOT HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1718 E 4TH ST | ||||||||
| Address2: | SUITE 902 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282043261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3364763338 | ||||||||
| FaxNumber: | 3364750165 | ||||||||
| Practice Location | |||||||||
| Address1: | 211 OLD LEXINGTON RD | ||||||||
| Address2: | |||||||||
| City: | THOMASVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273603428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3364763338 | ||||||||
| FaxNumber: | 3364750165 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 04/08/2009 | ||||||||
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| AuthorizedOfficialLastName: | GRIER | ||||||||
| AuthorizedOfficialFirstName: | MICHELE | ||||||||
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| AuthorizedOfficialTitleorPosition: | SVP/COO OF NMG | ||||||||
| AuthorizedOfficialTelephone: | 3362772421 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FORSYTH MEDICAL GROUP, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302R00000X | N | Managed Care Organizations | Health Maintenance Organization | 213E00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 5250070001 | 01 | NC | DME NUMBER | OTHER | 7901114 | 05 | NC | MEDICAID |