Basic Information
| Provider Information | |||||||||
| NPI: | 1467497081 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PIEDMONT TRIAD ANESTHESIA, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 145 KIMEL PARK DR | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271036983 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367683212 | ||||||||
| FaxNumber: | 3367689019 | ||||||||
| Practice Location | |||||||||
| Address1: | 145 KIMEL PARK DR | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | WINSTON-SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271036983 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367683212 | ||||||||
| FaxNumber: | 3367689019 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2006 | ||||||||
| LastUpdateDate: | 08/10/2011 | ||||||||
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| AuthorizedOfficialLastName: | FYOCK | ||||||||
| AuthorizedOfficialFirstName: | THEODORE | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3367683212 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 367500000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207L00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 016HA | 01 | NC | BCBS | OTHER | 89016HA | 05 | NC | MEDICAID | 8000325 | 05 | NC | MEDICAID | DC6484 | 01 | NC | RR MEDICARE | OTHER |