Basic Information
| Provider Information | |||||||||
| NPI: | 1316303076 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BETHANY MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 507 N LINDSAY ST | ||||||||
| Address2: | |||||||||
| City: | HIGH POINT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272624303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368830029 | ||||||||
| FaxNumber: | 3368830867 | ||||||||
| Practice Location | |||||||||
| Address1: | 3402 BATTLEGROUND AVE | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274102404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368830029 | ||||||||
| FaxNumber: | 3368830867 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2016 | ||||||||
| LastUpdateDate: | 01/20/2016 | ||||||||
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| AuthorizedOfficialLastName: | PETERS | ||||||||
| AuthorizedOfficialFirstName: | LENIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 3368830029 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 103837 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207N00000X | 36839 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207RC0000X | 2013-01110 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RG0100X | 101104 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RP1001X | 35265 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7901101 | 05 | NC | MEDICAID | 2316178 | 05 | NC | MEDICAID | 3409940 | 05 | NC | MEDICAID | 89011F1 | 05 | NC | MEDICAID | 5607644 | 05 | NC | MEDICAID | 1619398997 | 05 | NC | MEDICAID | 1780015842 | 05 | NC | MEDICAID | 1992133870 | 05 | NC | MEDICAID |