Provider Demographics
NPI:1063460970
Name:FORSYTH MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:FORSYTH MEDICAL GROUP, LLC
Other - Org Name:NOVANT HEALTH WILKES MEDICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RCS MGR
Authorized Official - Prefix:
Authorized Official - First Name:SHALA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-303-7517
Mailing Address - Street 1:PO BOX 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:336-651-2980
Mailing Address - Fax:336-667-2047
Practice Address - Street 1:1919 W PARK DR
Practice Address - Street 2:
Practice Address - City:NORTH WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28659-3564
Practice Address - Country:US
Practice Address - Phone:336-651-2980
Practice Address - Fax:336-667-2047
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FORSYTH MEDICAL GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-04
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89015U3Medicaid
NCCJ2926OtherRAILROAD MEDICARE
NC2344744Medicare PIN