Provider Demographics
NPI:1891828562
Name:FORSYTH MEMORIAL HOSPITAL, INC
Entity Type:Organization
Organization Name:FORSYTH MEMORIAL HOSPITAL, INC
Other - Org Name:WEST FORSYTH INTERNAL MEDICINE & PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RCS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHALA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-303-7517
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:336-718-4820
Mailing Address - Fax:
Practice Address - Street 1:105 STADIUM OAKS DR
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-8962
Practice Address - Country:US
Practice Address - Phone:336-766-0547
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC019C7OtherBLUECROSS BLUESHIELD
NCJ971OtherBLUE MEDICARE
NCCA1315OtherRAILROAD MEDICARE
NC890296WMedicaid
NCJ971OtherBLUE MEDICARE
NC2351681KMedicare PIN