Basic Information
| Provider Information | |||||||||
| NPI: | 1346487964 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FORSYTHE MEMORIAL HOSPITAL, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MAPLEWOOD FAMILY PRACTICE AT THE VILLAGE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 5110 ROBINHOOD VILLAGE DR | ||||||||
| Address2: | SUITE C-1 | ||||||||
| City: | WINSTON-SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271065476 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367180800 | ||||||||
| FaxNumber: | 3367180871 | ||||||||
| Practice Location | |||||||||
| Address1: | 5110 ROBINHOOD VILLAGE DR | ||||||||
| Address2: | SUITE C-1 | ||||||||
| City: | WINSTON-SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271065476 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367180800 | ||||||||
| FaxNumber: | 3367180871 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2009 | ||||||||
| LastUpdateDate: | 01/20/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GRIER | ||||||||
| AuthorizedOfficialFirstName: | MICHELE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SVP/COO | ||||||||
| AuthorizedOfficialTelephone: | 3362772421 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.