Basic Information
| Provider Information | |||||||||
| NPI: | 1255542742 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FORSYTH MEDICAL GROUP LLC | ||||||||
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| OtherOrganizationName: | UROLOGY PARTNERS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 FRONTIS PLAZA BLVD STE 200 | ||||||||
| Address2: | ATTN FORSYTH MEDICAL GROUP | ||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271035616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362772436 | ||||||||
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| Practice Location | |||||||||
| Address1: | 180 KIMEL PARK DR STE 110 | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271036970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362771717 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MATTHEWS | ||||||||
| AuthorizedOfficialFirstName: | MARIMARTHA | ||||||||
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| AuthorizedOfficialTitleorPosition: | FMG MANAGED CARE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3362772436 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
No ID Information.