Provider Demographics
NPI:1891008207
Name:MOSES CONE AFFILIATED PHYSICIANS, INC.
Entity Type:Organization
Organization Name:MOSES CONE AFFILIATED PHYSICIANS, INC.
Other - Org Name:PRESTON S. CLARK, MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO/TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:K
Authorized Official - Last Name:BOGGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-832-8005
Mailing Address - Street 1:1200 NORTH ELM STREET
Mailing Address - Street 2:MOSES CONE HEALTH SYSTEM-ADMINISTRATIVE SVC. STE. 201
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-1020
Mailing Address - Country:US
Mailing Address - Phone:336-832-8005
Mailing Address - Fax:336-832-8272
Practice Address - Street 1:1200 NORTH ELM STREET
Practice Address - Street 2:MOSES CONE HEALTH SYSTEM-ADMINISTRATIVE SVC, STE. 201
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1020
Practice Address - Country:US
Practice Address - Phone:336-832-8005
Practice Address - Fax:336-832-8272
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE MOSES H. CONE MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-07-15
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207R00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5914946Medicaid
NC2347353AMedicare PIN