Basic Information
Provider Information | |||||||||
NPI: | 1912051939 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FORSYTH MEMORIAL HOSPITAL, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | FRIEDBURG FAMILY MEDICINE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2000 FRONTIS PLAZA BLVD STE 102 | ||||||||
Address2: | FORSYTH MEDICAL GROUP, LLC | ||||||||
City: | WINSTON SALEM | ||||||||
State: | NC | ||||||||
PostalCode: | 271035616 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3367884664 | ||||||||
FaxNumber: | 3367880753 | ||||||||
Practice Location | |||||||||
Address1: | 5010 PETERS CREEK PKWY | ||||||||
Address2: | DBA FRIEDBURG FAMILY MEDICINE | ||||||||
City: | WINSTON SALEM | ||||||||
State: | NC | ||||||||
PostalCode: | 271277276 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3367884664 | ||||||||
FaxNumber: | 3367880753 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/23/2007 | ||||||||
LastUpdateDate: | 08/14/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GRIER | ||||||||
AuthorizedOfficialFirstName: | MICHELE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP OPERATIONS | ||||||||
AuthorizedOfficialTelephone: | 3367884664 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | FORSYTH MEMORIAL HOSPITAL, INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
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 | 019C9 | 01 | NC | BCBS PIN | OTHER | 5906033 | 05 | NC |   | MEDICAID |