Provider Demographics
NPI:1750342820
Name:ARDMORE FAMILY PRACTICE P.A.
Entity type:Organization
Organization Name:ARDMORE FAMILY PRACTICE P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:H
Authorized Official - Last Name:ALFORD
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:336-659-0076
Mailing Address - Street 1:2805 LYNDHURST AVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-4109
Mailing Address - Country:US
Mailing Address - Phone:336-659-0076
Mailing Address - Fax:336-659-0272
Practice Address - Street 1:2805 LYNDHURST AVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4109
Practice Address - Country:US
Practice Address - Phone:336-659-0076
Practice Address - Fax:336-659-0272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-29
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7902204Medicaid
NY7902204Medicaid