Provider Demographics
NPI:1861471419
Name:BRIDDELL, MARY L (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:BRIDDELL
Suffix:
Gender:F
Credentials:NP
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Other - First Name:
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Other - Last Name:
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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:336-277-2436
Mailing Address - Fax:
Practice Address - Street 1:207 OLD LEXINGTON RD
Practice Address - Street 2:SPINE CENTER OF TMC
Practice Address - City:THOMASVILLE
Practice Address - State:NC
Practice Address - Zip Code:27360-3428
Practice Address - Country:US
Practice Address - Phone:336-475-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC201740363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2344744Medicare ID - Type Unspecified
P91013Medicare UPIN