Provider Demographics
NPI:1912198672
Name:FORSYTH MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:FORSYTH MEDICAL GROUP, LLC
Other - Org Name:WINSTON-SALEM HEALTHCARE (CAPITATION PLAN)
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ENROLLMENT COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:HEAVENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADSHAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-679-2661
Mailing Address - Street 1:2000 FRONTIS PLAZA BLVD STE 102
Mailing Address - Street 2:NOVANT MEDICAL GROUP
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-5616
Mailing Address - Country:US
Mailing Address - Phone:336-718-1000
Mailing Address - Fax:336-718-1298
Practice Address - Street 1:250 CHARLOIS BLVD
Practice Address - Street 2:DBA WINSTON-SALEM HEALTHCARE (CAPITATED PLAN)
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1508
Practice Address - Country:US
Practice Address - Phone:336-718-1000
Practice Address - Fax:336-718-1298
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FORSYTH MEDICAL GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-07
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic OncologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC015WWOtherBCBS CAPITATION NUMBER
NC590118PMedicaid
NCCJ2926OtherRAILROAD MEDICARE
NC590118PMedicaid