Basic Information
| Provider Information | |||||||||
| NPI: | 1598723488 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FORSYTH MEMORIAL HOSPITAL, INC | ||||||||
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| OtherOrganizationName: | MEDICAL ASSOCIATES OF SURRY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1718 E 4TH ST | ||||||||
| Address2: | SUITE 902 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282043261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367196100 | ||||||||
| FaxNumber: | 3367192313 | ||||||||
| Practice Location | |||||||||
| Address1: | 865 W LAKE DR | ||||||||
| Address2: | |||||||||
| City: | MOUNT AIRY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270302157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367196100 | ||||||||
| FaxNumber: | 3367192313 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2006 | ||||||||
| LastUpdateDate: | 08/24/2010 | ||||||||
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| AuthorizedOfficialLastName: | LINDSAY | ||||||||
| AuthorizedOfficialFirstName: | JEFFERY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT OF FMC | ||||||||
| AuthorizedOfficialTelephone: | 3367182056 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FORSYTH MEMORIAL HOSPITAL, INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207Q00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5902732 | 05 | NC | MEDICAID | CA1315 | 01 | NC | RAILROAD MEDICARE | OTHER |