Provider Demographics
NPI:1023056603
Name:BETHESDA CLINIC PA
Entity type:Organization
Organization Name:BETHESDA CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:S
Authorized Official - Last Name:GABY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-765-9750
Mailing Address - Street 1:3000 BETHESDA PLACE
Mailing Address - Street 2:STE 101 BETHESDA CLINIC PA
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103
Mailing Address - Country:US
Mailing Address - Phone:336-765-9750
Mailing Address - Fax:336-765-9710
Practice Address - Street 1:3000 BETHESDA PLACE
Practice Address - Street 2:STE 101 BETHESDA CLINIC PA
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103
Practice Address - Country:US
Practice Address - Phone:336-765-9750
Practice Address - Fax:336-765-9710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC246532084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8934253Medicaid
206478CMedicare ID - Type Unspecified
C8934Medicare UPIN