Basic Information
Provider Information | |||||||||
NPI: | 1063463156 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PRESBYTERIAN MEDICAL CARE CORP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | NOVANT HEALTH MATTHEWS MEDICAL CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2085 FRONTIS PLAZA BLVD | ||||||||
Address2: |   | ||||||||
City: | WINSTON-SALEM | ||||||||
State: | NC | ||||||||
PostalCode: | 271035614 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3362777226 | ||||||||
FaxNumber: | 3362779795 | ||||||||
Practice Location | |||||||||
Address1: | 1500 MATTHEWS TOWNSHIP PKWY | ||||||||
Address2: |   | ||||||||
City: | MATTHEWS | ||||||||
State: | NC | ||||||||
PostalCode: | 281054656 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7043846500 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/13/2006 | ||||||||
LastUpdateDate: | 04/13/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BERND | ||||||||
AuthorizedOfficialFirstName: | JASON | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT & CHIEF OPERATING OFFICER | ||||||||
AuthorizedOfficialTelephone: | 7043849261 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/13/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | H0270 | NC | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 3400171 | 05 | NC |   | MEDICAID |