Provider Demographics
NPI:1245244094
Name:FORSYTH MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:FORSYTH MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SPARE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-718-2046
Mailing Address - Street 1:2000 FRONTIS PLAZA BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-5616
Mailing Address - Country:US
Mailing Address - Phone:336-718-4820
Mailing Address - Fax:
Practice Address - Street 1:2000 FRONTIS PLAZA BLVD STE 2000
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-5616
Practice Address - Country:US
Practice Address - Phone:336-718-4820
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1063460970OtherMA WILKES
NC1396703237OtherDAVIDSON CARDIOLOGY-NPI #
NC1477738714OtherSPORTS MEDICINE ASSOC NPI
NC1750339834OtherTO/FAMILY FOOT NPI #
NC1619925641OtherFORSYTH PEDS NPI #
NC1912955055OtherWSHC NPI #
NC1245288786OtherDENT-NPI #
NC1285682310OtherWSCA NPI #
NC2344744Medicare PIN