Basic Information
| Provider Information | |||||||||
| NPI: | 1528554631 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BETHANY MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | BETHANY MEDICAL PAIN CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 507 N LINDSAY ST | ||||||||
| Address2: | |||||||||
| City: | HIGH POINT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272624303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368830029 | ||||||||
| FaxNumber: | 3368992176 | ||||||||
| Practice Location | |||||||||
| Address1: | 160 KIMEL FOREST DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271036084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368830029 | ||||||||
| FaxNumber: | 3368992176 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2018 | ||||||||
| LastUpdateDate: | 02/27/2020 | ||||||||
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| AuthorizedOfficialLastName: | PETERS | ||||||||
| AuthorizedOfficialFirstName: | LENIN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3368830029 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BETHANY MEDICAL CENTER | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 02/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.