Provider Demographics
NPI:1790971398
Name:PIEDMONT COMMUNITY PHYSICIANS, PC
Entity Type:Organization
Organization Name:PIEDMONT COMMUNITY PHYSICIANS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CAO
Authorized Official - Prefix:MR
Authorized Official - First Name:DICKSON
Authorized Official - Middle Name:M
Authorized Official - Last Name:CAPPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-765-0187
Mailing Address - Street 1:PO BOX 26822
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27114-6822
Mailing Address - Country:US
Mailing Address - Phone:336-765-0185
Mailing Address - Fax:336-768-3636
Practice Address - Street 1:3610 DARREN RD
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-9077
Practice Address - Country:US
Practice Address - Phone:336-765-0187
Practice Address - Fax:336-768-3636
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PIEDMONT COMMUNITY PHYSICIANS, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-18
Last Update Date:2018-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9900105207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCG90885Medicare UPIN
NC2263379AMedicare PIN
NC2325473AMedicare PIN