Provider Demographics
NPI:1619398997
Name:BETHANY MEDICAL CENTER
Entity Type:Organization
Organization Name:BETHANY MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:LENIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-883-0029
Mailing Address - Street 1:507 N LINDSAY ST
Mailing Address - Street 2:
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27262-4303
Mailing Address - Country:US
Mailing Address - Phone:336-883-0029
Mailing Address - Fax:336-899-2188
Practice Address - Street 1:495 ARBOR HILL RD STE M
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-3335
Practice Address - Country:US
Practice Address - Phone:336-883-0029
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BETHANY MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-01-03
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207ZC0500X, 207ZP0101X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathologyGroup - Multi-Specialty
No207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic PathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5907644Medicaid
NC3409940Medicaid
NC7901101Medicaid
NC89011F1Medicaid
NC2316178Medicare UPIN
NC2316178DMedicare UPIN
NC3409940Medicaid
NC89011F1Medicaid