Basic Information
| Provider Information | |||||||||
| NPI: | 1124171160 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FORSYTH MEDICAL GROUP, LLC | ||||||||
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| OtherOrganizationName: | FORSYTH PEDIATRICS OAK RIDGE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 FRONTIS PLAZA BLVD STE 200 | ||||||||
| Address2: | FORSYTH MEDICAL GROUP | ||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271035616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362772435 | ||||||||
| FaxNumber: | 3362779275 | ||||||||
| Practice Location | |||||||||
| Address1: | 2205 OAK RIDGE RD STE BB | ||||||||
| Address2: | DBA FORSYTH PEDIATRICS OAKRIDGE | ||||||||
| City: | OAK RIDGE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273108738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3366440994 | ||||||||
| FaxNumber: | 3366440997 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | EVERHART | ||||||||
| AuthorizedOfficialFirstName: | LYNN | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, MANAGED CARE | ||||||||
| AuthorizedOfficialTelephone: | 3362771477 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 363A00000X | X | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | X | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.