Provider Demographics
NPI:1952579807
Name:CEDAR CREEK FAMILY MEDICINE PLLC
Entity type:Organization
Organization Name:CEDAR CREEK FAMILY MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:R
Authorized Official - Last Name:NIFONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-784-0505
Mailing Address - Street 1:5350 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27107-9174
Mailing Address - Country:US
Mailing Address - Phone:336-784-0505
Mailing Address - Fax:
Practice Address - Street 1:11492 OLD US HIGHWAY 52
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27107-9497
Practice Address - Country:US
Practice Address - Phone:336-784-0505
Practice Address - Fax:336-784-0531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-13
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC88463261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH014U9OtherBLUE CROSS BLUE SHIELD
NC89014U9Medicaid
NC2333788Medicare PIN