Basic Information
| Provider Information | |||||||||
| NPI: | 1073792974 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WENTWORTH | ||||||||
| FirstName: | STACY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1317 N ELM ST | ||||||||
| Address2: | STE. 1B | ||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274011033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362749617 | ||||||||
| FaxNumber: | 3364822177 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 N. ELAM AVENUE | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368321100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2007 | ||||||||
| LastUpdateDate: | 08/10/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 2007-00580 | NC | N | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0001X | 200700580 | NC | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 1073792974 | 05 | VA | MEDICAID | P00838358 | 01 | NC | MEDICARE RAILROAD | OTHER | 5912234 | 05 | NC | MEDICAID |