Basic Information
| Provider Information | |||||||||
| NPI: | 1952404188 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BETHANY MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2403 | ||||||||
| Address2: | |||||||||
| City: | HIGH POINT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272612403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368830029 | ||||||||
| FaxNumber: | 3368838988 | ||||||||
| Practice Location | |||||||||
| Address1: | 507 N LINDSAY ST | ||||||||
| Address2: | |||||||||
| City: | HIGH POINT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272624303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368830029 | ||||||||
| FaxNumber: | 3368838988 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2006 | ||||||||
| LastUpdateDate: | 05/02/2022 | ||||||||
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| AuthorizedOfficialLastName: | PETERS | ||||||||
| AuthorizedOfficialFirstName: | LENIN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3368830029 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 05/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RP1001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 291U00000X | N | Laboratories | Clinical Medical Laboratory | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7901101 | 05 | NC | MEDICAID |