Provider Demographics
NPI:1114368560
Name:PIEDMONT OCCUPATIONAL & GENERAL MEDICINE
Entity Type:Organization
Organization Name:PIEDMONT OCCUPATIONAL & GENERAL MEDICINE
Other - Org Name:PIEDMONT OCCUPATIONAL URGENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:D
Authorized Official - Last Name:PRUITT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-453-3446
Mailing Address - Street 1:217 TURNER DR STE A
Mailing Address - Street 2:
Mailing Address - City:REIDSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27320-5754
Mailing Address - Country:US
Mailing Address - Phone:336-349-4070
Mailing Address - Fax:
Practice Address - Street 1:217 TURNER DR STE A
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320-5754
Practice Address - Country:US
Practice Address - Phone:336-349-4070
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-15
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9400512208D00000X, 261QX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC893786EMedicaid