Provider Demographics
NPI:1780642629
Name:FORSYTH MEMORIAL HOSPITAL INC
Entity Type:Organization
Organization Name:FORSYTH MEMORIAL HOSPITAL INC
Other - Org Name:NOVANT HEALTH CLEMMONS FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RCS MGR
Authorized Official - Prefix:
Authorized Official - First Name:SHALA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-303-7517
Mailing Address - Street 1:PO BOX 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:704-384-9144
Mailing Address - Fax:704-417-1043
Practice Address - Street 1:6301 STADIUM DR
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-8766
Practice Address - Country:US
Practice Address - Phone:336-766-6473
Practice Address - Fax:336-766-8909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-02
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC015AAOtherBLUECROSS BLUESHIELD
NC89015AAMedicaid
NCCA1315OtherRAILROAD MEDICARE
NC106OtherBLUE MEDICARE
NC106OtherBLUE MEDICARE
NC340014Medicare Oscar/Certification