Basic Information
| Provider Information | |||||||||
| NPI: | 1144575929 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARDINAL HEALTH SERVICES, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 30575 | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271300575 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3364480962 | ||||||||
| FaxNumber: | 3369923930 | ||||||||
| Practice Location | |||||||||
| Address1: | 3069 TRENWEST DR | ||||||||
| Address2: | STE 200 | ||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271033211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3364480962 | ||||||||
| FaxNumber: | 3369923930 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2012 | ||||||||
| LastUpdateDate: | 12/12/2012 | ||||||||
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| AuthorizedOfficialLastName: | TRIPP | ||||||||
| AuthorizedOfficialFirstName: | HENRY | ||||||||
| AuthorizedOfficialMiddleName: | FRANKLIN | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3369933146 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 32185 | NC | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 207QG0300X | 32185 | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 34D2049903 | 01 | NC | CLIA # | OTHER |