Provider Demographics
NPI:1003829821
Name:GUILFORD MEDICAL CENTER, PA
Entity Type:Organization
Organization Name:GUILFORD MEDICAL CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JYOTHI
Authorized Official - Middle Name:NAT
Authorized Official - Last Name:MANN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-275-1306
Mailing Address - Street 1:1593 YANCEYVILLE ST.
Mailing Address - Street 2:SUITE 100, BLDG A
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-6948
Mailing Address - Country:US
Mailing Address - Phone:336-275-1306
Mailing Address - Fax:336-275-1307
Practice Address - Street 1:1593 YANCEYVILLE ST
Practice Address - Street 2:SUITE 100, BLDG A
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-6948
Practice Address - Country:US
Practice Address - Phone:336-275-1306
Practice Address - Fax:336-275-1307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC930039207RG0100X
NC2005-00334207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0254UOtherBLUE CROSS BLUE SHIELD
NC890245UMedicaid
NC0254UOtherBLUE CROSS BLUE SHIELD
NC890245UMedicaid