Basic Information
| Provider Information | |||||||||
| NPI: | 1558329318 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FOUNDATION HEALTH SYSTEMS CORP | ||||||||
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| OtherOrganizationName: | EDWIN H. MARTINAT COMPREHENSIVE OUTPATIENT REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 FRONTIS PLAZA BLVD STE 200 | ||||||||
| Address2: | (ATTN) FORSYTH MEDICAL GROUP | ||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271035616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362772435 | ||||||||
| FaxNumber: | 3362779275 | ||||||||
| Practice Location | |||||||||
| Address1: | 109 GATEWAY CENTER DR | ||||||||
| Address2: | DBA EDWIN H. MARTINAT | ||||||||
| City: | KERNERSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272842999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3369967001 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | LINER | ||||||||
| AuthorizedOfficialFirstName: | SALLYE | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXE.VP & CCO & ADMIN | ||||||||
| AuthorizedOfficialTelephone: | 3367182004 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | X | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | X | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 235Z00000X | X | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 332B00000X | X | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.