Basic Information
| Provider Information | |||||||||
| NPI: | 1326277062 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FORSYTH MEMORIAL HOSPITAL INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NOVANT HEALTH NEW GARDEN MEDICAL ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 751803 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282751803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362888857 | ||||||||
| FaxNumber: | 3362888769 | ||||||||
| Practice Location | |||||||||
| Address1: | 1941 NEW GARDEN RD | ||||||||
| Address2: | SUITE 216 | ||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274102555 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362888857 | ||||||||
| FaxNumber: | 3362888769 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2009 | ||||||||
| LastUpdateDate: | 07/03/2013 | ||||||||
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| AuthorizedOfficialLastName: | LANGFORD | ||||||||
| AuthorizedOfficialFirstName: | KATHRYN | ||||||||
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| AuthorizedOfficialTitleorPosition: | SVP & COO NOVANT MEDICAL GROUP | ||||||||
| AuthorizedOfficialTelephone: | 7043847606 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5950709 | 05 | NC | MEDICAID | 1326277062 | 01 | NC | BCBS | OTHER |