Basic Information
| Provider Information | |||||||||
| NPI: | 1619398997 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BETHANY MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 507 N LINDSAY ST | ||||||||
| Address2: | |||||||||
| City: | HIGH POINT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272624303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368830029 | ||||||||
| FaxNumber: | 3368992188 | ||||||||
| Practice Location | |||||||||
| Address1: | 495 ARBOR HILL RD STE M | ||||||||
| Address2: | |||||||||
| City: | KERNERSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272843335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368830029 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2014 | ||||||||
| LastUpdateDate: | 04/06/2021 | ||||||||
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| AuthorizedOfficialLastName: | PETERS | ||||||||
| AuthorizedOfficialFirstName: | LENIN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 3368830029 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BETHANY MEDICAL CENTER | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 04/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZC0500X | NC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | 207ZP0101X | NC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology | 207ZP0102X | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 5907644 | 05 | NC | MEDICAID | 3409940 | 05 | NC | MEDICAID | 7901101 | 05 | NC | MEDICAID | 89011F1 | 05 | NC | MEDICAID |