Basic Information
| Provider Information | |||||||||
| NPI: | 1386614212 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EVANS | ||||||||
| FirstName: | CHARLOTTE | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 FRONTIS PLAZA BLVD STE 200 | ||||||||
| Address2: | (ATTN) FORSYTH MEDICAL GROUP | ||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271035616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362772435 | ||||||||
| FaxNumber: | 3362779275 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 CHATHAM MEDICAL PARK | ||||||||
| Address2: | DBA FOOTHILLS FAMILY MEDICINE | ||||||||
| City: | ELKIN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286212482 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368354819 | ||||||||
| FaxNumber: | 3368356934 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 30332 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8930903 | 05 | NC | MEDICAID |