Basic Information
| Provider Information | |||||||||
| NPI: | 1427697978 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NOVANT HEALTH CLEMMONS OUTPATIENT SURGERY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 N CHERRY ST | ||||||||
| Address2: | STE 600 | ||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271014013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362771604 | ||||||||
| FaxNumber: | 3362779584 | ||||||||
| Practice Location | |||||||||
| Address1: | 7210 VILLAGE MEDICAL CIRCEL | ||||||||
| Address2: | STE 235 | ||||||||
| City: | CLEMMONS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368933100 | ||||||||
| FaxNumber: | 3368933109 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2020 | ||||||||
| LastUpdateDate: | 01/02/2020 | ||||||||
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| AuthorizedOfficialLastName: | GREEN | ||||||||
| AuthorizedOfficialFirstName: | GERALD | ||||||||
| AuthorizedOfficialMiddleName: | OSBORNE | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR ASC | ||||||||
| AuthorizedOfficialTelephone: | 3362771782 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 126701 | 01 | NC | AAAHC | OTHER |