Basic Information
Provider Information | |||||||||
NPI: | 1578511606 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FORSYTH MEMORIAL HOSPITAL INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | NOVANT HEALTH FORSYTH INTERNAL MEDICINE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 751803 | ||||||||
Address2: |   | ||||||||
City: | CHARLOTTE | ||||||||
State: | NC | ||||||||
PostalCode: | 282751803 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7043847606 | ||||||||
FaxNumber: | 3362777722 | ||||||||
Practice Location | |||||||||
Address1: | 1381 WESTGATE CENTER DR | ||||||||
Address2: |   | ||||||||
City: | WINSTON-SALEM | ||||||||
State: | NC | ||||||||
PostalCode: | 271032934 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3367180100 | ||||||||
FaxNumber: | 3367180120 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/04/2006 | ||||||||
LastUpdateDate: | 07/02/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LANGFORD | ||||||||
AuthorizedOfficialFirstName: | KATHRYN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | SVP & COO NOVANT MEDICAL GROUP | ||||||||
AuthorizedOfficialTelephone: | 7043847606 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 5425016 | 01 | NC | AETNA ID# | OTHER | 6901531 | 05 | NC |   | MEDICAID | CA1315 | 01 | NC | RAILROAD MCR ID# | OTHER | 2330 | 01 | NC | PARTNERS ID# | OTHER | 01531 | 01 | NC | BCBD ID# | OTHER |