Basic Information
| Provider Information | |||||||||
| NPI: | 1699733485 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FORSYTH MEDICAL GROUP, LLC | ||||||||
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| OtherOrganizationName: | WINSTON-SALEM CARDIOLOGY ASSOC. | ||||||||
| 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: | 1919 W PARK DR | ||||||||
| Address2: | DBA WINSTON-SALEM CARDIOLOGY | ||||||||
| City: | N WILKESBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286593564 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3366674350 | ||||||||
| FaxNumber: | 3368388403 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | EVERHART | ||||||||
| AuthorizedOfficialFirstName: | LYNN | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGED CARE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3362772433 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 363A00000X | X | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | X | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 7901159 | 05 | NC | MEDICAID |