Provider Demographics
NPI:1710945696
Name:CAROLINA MEDICORP ENTERPRISES, INC
Entity Type:Organization
Organization Name:CAROLINA MEDICORP ENTERPRISES, INC
Other - Org Name:PRIMCE CARE OF KERNERSVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:M
Authorized Official - Last Name:BARRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-774-0040
Mailing Address - Street 1:2000 FRONTIS PLAZA BLVD STE 200
Mailing Address - Street 2:(ATTN) FORSYTH MEDICAL GROUP
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-5616
Mailing Address - Country:US
Mailing Address - Phone:336-277-2435
Mailing Address - Fax:336-277-9275
Practice Address - Street 1:111 GATEWAY CENTER DR
Practice Address - Street 2:DBA PRIMECARE KERNERSVILLE
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-2999
Practice Address - Country:US
Practice Address - Phone:336-996-2173
Practice Address - Fax:336-996-3254
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CAROLINA MEDICORP ENTERPRISES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-02
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - 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
NC89012MMedicaid
NC89012MMedicaid