Basic Information
| Provider Information | |||||||||
| NPI: | 1851313332 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILLIFORD | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | ANN KIDWELL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1701 WESTCHESTER DRIVE | ||||||||
| Address2: | SUITE 850 | ||||||||
| City: | HIGH POINT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272627254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368022400 | ||||||||
| FaxNumber: | 3368022001 | ||||||||
| Practice Location | |||||||||
| Address1: | MEDICAL CENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271574324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367165599 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2006 | ||||||||
| LastUpdateDate: | 09/18/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 29454 | NC | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RH0003X | 29454 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 110122233 | 01 | NC | RR MEDICARE | OTHER | 8988077 | 05 | NC | MEDICAID |