Provider Demographics
NPI:1851371066
Name:FORSYTH MEMORIAL HOSPITAL INC
Entity Type:Organization
Organization Name:FORSYTH MEMORIAL HOSPITAL INC
Other - Org Name:NOVANT HEALTH PREMIER MEDICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EDI MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LEEA
Authorized Official - Middle Name:JEANINE
Authorized Official - Last Name:WALTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-316-6081
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:336-774-3740
Mailing Address - Fax:336-774-3780
Practice Address - Street 1:3333 BROOKVIEW HILLS BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-5661
Practice Address - Country:US
Practice Address - Phone:336-774-3740
Practice Address - Fax:336-774-3780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-23
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily 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
NC015TKOtherGROUP BCBS NUMBER
NC2452425OtherGROUP UHC NUMBER
NC02570OtherGROUP AETNA NUMBER
NCCA89015TKMedicaid
NC2337041Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER
NCCA89015TKMedicaid