Provider Demographics
NPI:1851713374
Name:WINSTON-SALEM STATE UNIVERSITY
Entity Type:Organization
Organization Name:WINSTON-SALEM STATE UNIVERSITY
Other - Org Name:WELLNESS CTR. STUDENT BLUE
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILADELPHIA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:336-750-3274
Mailing Address - Street 1:601 S MARTIN LUTHER KING JR DR
Mailing Address - Street 2:A.H. RAY BLDG RM. 244
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27110-0001
Mailing Address - Country:US
Mailing Address - Phone:336-750-3301
Mailing Address - Fax:336-750-3303
Practice Address - Street 1:601 S MARTIN LUTHER KING JR DR
Practice Address - Street 2:A.H. RAY BLDG RM. 244
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27110-0001
Practice Address - Country:US
Practice Address - Phone:336-750-3301
Practice Address - Fax:336-750-3303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-17
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent HealthGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7000169Medicaid
NC7000169Medicaid