Basic Information
| Provider Information | |||||||||
| NPI: | 1306849047 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JENNINGS | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | BRYAN | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4601 PARK RD STE 250 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282092373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043232000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 170 KIMEL PARK DR | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367681270 | ||||||||
| FaxNumber: | 3367656375 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2005 | ||||||||
| LastUpdateDate: | 08/13/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | 200400218 | NC | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207X00000X | 200400218 | NC | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 89136WG | 05 | NC | MEDICAID | 1306849047 | 05 | NC | MEDICAID | 0223770001 | 01 | NC | MEDICARE DME | OTHER |