Provider Demographics
NPI:1003858721
Name:PIEDMONT ENDOSCOPY CENTER, INC.
Entity Type:Organization
Organization Name:PIEDMONT ENDOSCOPY CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSITANT ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:L
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:CMPE
Authorized Official - Phone:336-714-3544
Mailing Address - Street 1:1901 S HAWTHORNE RD
Mailing Address - Street 2:SUITE 308
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-3921
Mailing Address - Country:US
Mailing Address - Phone:336-760-4340
Mailing Address - Fax:336-765-2869
Practice Address - Street 1:1901 S HAWTHORNE RD
Practice Address - Street 2:SUITE 308
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3921
Practice Address - Country:US
Practice Address - Phone:336-760-4340
Practice Address - Fax:336-765-2869
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCAS0044261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3409863Medicaid
NC2380290Medicare ID - Type Unspecified