Basic Information
| Provider Information | |||||||||
| NPI: | 1902909328 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FORSYTH CARDIAC & VASCULAR SURGEONS, P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4622 COUNTRY CLUB RD | ||||||||
| Address2: | SUITE 180 | ||||||||
| City: | WINSTON-SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271043770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367689535 | ||||||||
| FaxNumber: | 3367684155 | ||||||||
| Practice Location | |||||||||
| Address1: | 4622 COUNTRY CLUB RD | ||||||||
| Address2: | SUITE 180 | ||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271043770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367689535 | ||||||||
| FaxNumber: | 3367684155 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2006 | ||||||||
| LastUpdateDate: | 10/27/2010 | ||||||||
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| AuthorizedOfficialLastName: | RODRIGUEZ | ||||||||
| AuthorizedOfficialFirstName: | PENNY | ||||||||
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| AuthorizedOfficialTitleorPosition: | AR & CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3367949616 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | 40490 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 890127F | 05 | NC | MEDICAID |