MEDICARE: MRS. NANCY IRENE FALLER DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208VP0000X	Pain Medicine Physician	9401402	NC
2	207LP2900X	Pain Medicine (Anesthesiology) Physician	9401402	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	13736	OTHER	NC	BLUE CROSS & BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	D8837	OTHER	NC	MEDCOST
4	05609128	OTHER	NC	AETNA

General Provider Information

NPI Number	:	1811952740
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. NANCY IRENE FALLER DO

Provider Business Mailing Address
First Line	:	145 KIMEL PARK DR
Second Line	:	SUITE 330
City	:	WINSTON SALEM
State	:	NC
Zip	:	27103-6984
Country	:	US
Telephone Number	:	336-765-6181
Fax Number	:	336-765-8492

Provider Business Practice Location Address
First Line	:	145 KIMEL PARK DR
Second Line	:	SUITE 330
City	:	WINSTON SALEM
State	:	NC
Zip	:	27103-6984
Country	:	US
Telephone Number	:	336-765-6181
Fax Number	:	336-765-8492

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/20/2006
Last Update Date	:	09/09/2020

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