Basic Information
| Provider Information | |||||||||
| NPI: | 1346427200 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FORSYTH MEMORIAL HOSPITAL INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | NOVANT HEALTH FORSYTH BEHAVIORAL HEALTH OUTPATIENT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 75216 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282750216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043849144 | ||||||||
| FaxNumber: | 7044171043 | ||||||||
| Practice Location | |||||||||
| Address1: | 175 KIMEL PARK DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271036951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362771800 | ||||||||
| FaxNumber: | 3362776981 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2008 | ||||||||
| LastUpdateDate: | 08/17/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | SHALA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | RCS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7043037517 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 89012TT | 01 | NC | BCBS GRP ID | OTHER | 89012TT | 05 | NC | MEDICAID |