Basic Information
| Provider Information | |||||||||
| NPI: | 1992133870 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BETHANY MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | BETHANY PATHOLOGY LAB | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 507 N LINDSAY ST | ||||||||
| Address2: | |||||||||
| City: | HIGH POINT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272624303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368830029 | ||||||||
| FaxNumber: | 3368992188 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 N BRIDGE ST | ||||||||
| Address2: | SUITE C | ||||||||
| City: | WILKESBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286972488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368830029 | ||||||||
| FaxNumber: | 3368992188 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2013 | ||||||||
| LastUpdateDate: | 10/31/2013 | ||||||||
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| AuthorizedOfficialLastName: | WOMBLE | ||||||||
| AuthorizedOfficialFirstName: | MANDY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3368830029 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BETHANY MEDICAL CENTER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZC0500X | NC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | 207ZP0101X | NC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology | 207ZP0102X | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 89011F1 | 05 | NC | MEDICAID | 3409940 | 05 | NC | MEDICAID | 5907644 | 05 | NC | MEDICAID | 7901101 | 05 | NC | MEDICAID |