Healthcare Provider Details

I. General information

NPI: 1356849152
Provider Name (Legal Business Name): FORSYTH MEMORIAL HOSPITAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2018
Last Update Date: 02/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5380 US HIGHWAY 158 STE 110
ADVANCE NC
27006-6974
US

IV. Provider business mailing address

PO BOX 751803
CHARLOTTE NC
28275-1803
US

V. Phone/Fax

Practice location:
  • Phone: 336-896-1477
  • Fax: 336-893-3229
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number
License Number StateNC

VIII. Authorized Official

Name: SHALA DAVIS
Title or Position: MANAGER NMG RCS
Credential:
Phone: 704-316-7845