Basic Information
| Provider Information | |||||||||
| NPI: | 1760853113 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FORSYTH MEMORIAL HOSPITAL INC | ||||||||
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| OtherOrganizationName: | NOVANT HEALTH CANCER PREVENTION AND WELLNESS CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 751803 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282751803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362776000 | ||||||||
| FaxNumber: | 3362776001 | ||||||||
| Practice Location | |||||||||
| Address1: | 3333 SILAS CREEK PKWY | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271033013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362778800 | ||||||||
| FaxNumber: | 3362776001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2015 | ||||||||
| LastUpdateDate: | 12/24/2015 | ||||||||
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| AuthorizedOfficialLastName: | GARDNER | ||||||||
| AuthorizedOfficialFirstName: | GEOFFREY | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | VP NMG FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 3362778800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 100354 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207RH0003X | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 17608533113 | 05 | NC | MEDICAID |