Basic Information
| Provider Information | |||||||||
| NPI: | 1396889549 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SALEM PSYCHIATRIC ASSOC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 175 KIMEL PARK DR | ||||||||
| Address2: | SUITE 115 | ||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271036951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3366599440 | ||||||||
| FaxNumber: | 3366599845 | ||||||||
| Practice Location | |||||||||
| Address1: | 175 KIMEL PARK DR | ||||||||
| Address2: | SUITE 115 | ||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271036951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3366599440 | ||||||||
| FaxNumber: | 3366599845 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MCCAULEY | ||||||||
| AuthorizedOfficialFirstName: | ROGER | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3366599440 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TB0200X | 20823 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral |
ID Information
| ID | Type | State | Issuer | Description | 02594 | 01 | NC | BCBS | OTHER | 8902594 | 05 | NC | MEDICAID |