Provider Demographics
NPI:1477738714
Name:FORSYTH MEDICAL GROUP, LLC.
Entity Type:Organization
Organization Name:FORSYTH MEDICAL GROUP, LLC.
Other - Org Name:SPORTS MEDICINE ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-718-6720
Mailing Address - Street 1:2000 FRONTIS PLAZA BLVD STE 102
Mailing Address - Street 2:NOVANT MEDICAL GROUP, LLC.
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-5616
Mailing Address - Country:US
Mailing Address - Phone:336-718-6720
Mailing Address - Fax:
Practice Address - Street 1:1900 S HAWTHORNE RD STE 480
Practice Address - Street 2:DBA SPORTS MEDICINE ASSOCIATES
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3913
Practice Address - Country:US
Practice Address - Phone:336-277-1655
Practice Address - Fax:336-277-1650
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FORSYTH MEDICAL GROUP, LLC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-07
Last Update Date:2008-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2344744Medicare PIN