Provider Demographics
NPI:1811090475
Name:FORSYTH PLASTIC SURGICAL ASSOC PA
Entity type:Organization
Organization Name:FORSYTH PLASTIC SURGICAL ASSOC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ANDUSON
Authorized Official - Last Name:FAGG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-765-8620
Mailing Address - Street 1:2901 MAPLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103
Mailing Address - Country:US
Mailing Address - Phone:336-765-8620
Mailing Address - Fax:336-768-6236
Practice Address - Street 1:2901 MAPLEWOOD AVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103
Practice Address - Country:US
Practice Address - Phone:336-765-8620
Practice Address - Fax:336-768-6236
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200001225739208200000X
NC200001205450208200000X
NC20000119979208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty