Basic Information
| Provider Information | |||||||||
| NPI: | 1831376797 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FORSYTH MEMORIAL HOSPITAL, INC | ||||||||
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| OtherOrganizationName: | MEDICAL ASSOCIATES OF DAVIE - HILLSDALE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 FRONTIS PLAZA BLVD STE 102 | ||||||||
| Address2: | NOVANT MEDICAL GROUP | ||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271035616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362772435 | ||||||||
| FaxNumber: | 3362779275 | ||||||||
| Practice Location | |||||||||
| Address1: | 121 MEDICAL DR | ||||||||
| Address2: | DBA MEDICAL ASSOCIATES OF DAVIE - HILLSDALE | ||||||||
| City: | ADVANCE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270066651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3369989060 | ||||||||
| FaxNumber: | 3369989061 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2008 | ||||||||
| LastUpdateDate: | 01/23/2008 | ||||||||
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| AuthorizedOfficialLastName: | GRIER | ||||||||
| AuthorizedOfficialFirstName: | MICHELE | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 3362772421 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FORSYTH MEMORIAL HOSPITAL, INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02054 | 01 | NC | BCBS GRP ID# | OTHER | 7902054 | 05 | NC | MEDICAID |