Basic Information
| Provider Information | |||||||||
| NPI: | 1497713234 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FORSYTH MEMORIAL HOSPITAL INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NOVANT HEALTH MOUNTAINVIEW MEDICAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 751803 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282751803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7044174634 | ||||||||
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| Practice Location | |||||||||
| Address1: | 216 MOORE RD | ||||||||
| Address2: | |||||||||
| City: | KING | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270218703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3369834346 | ||||||||
| FaxNumber: | 3369855101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2006 | ||||||||
| LastUpdateDate: | 08/18/2021 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | SHALA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | RCS MGR | ||||||||
| AuthorizedOfficialTelephone: | 7043037517 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | CA1315 | 01 | NC | RAILROAD MEDICARE | OTHER | 890224P | 05 | NC | MEDICAID |