MEDICARE: FORSYTH MEMORIAL HOSPITAL, INC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	363A00000X	Physician Assistant
2	363L00000X	Nurse Practitioner
3	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	019C9	OTHER	NC	BCBS PIN
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1912051939
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORSYTH MEMORIAL HOSPITAL, INC

Provider Business Mailing Address
First Line	:	2000 FRONTIS PLAZA BLVD STE 102
Second Line	:	FORSYTH MEDICAL GROUP, LLC
City	:	WINSTON SALEM
State	:	NC
Zip	:	27103-5616
Country	:	US
Telephone Number	:	336-788-4664
Fax Number	:	336-788-0753

Provider Business Practice Location Address
First Line	:	5010 PETERS CREEK PKWY
Second Line	:	DBA FRIEDBURG FAMILY MEDICINE
City	:	WINSTON SALEM
State	:	NC
Zip	:	27127-7276
Country	:	US
Telephone Number	:	336-788-4664
Fax Number	:	336-788-0753

Authorized Official
Title or Position	:	VP OPERATIONS
Name	:	MICHELE GRIER
Credential	:
Telephone Number	:	336-788-4664

Provider Enumeration Date	:	01/23/2007
Last Update Date	:	08/14/2008

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