Healthcare Provider Details

I. General information

NPI: 1891828562
Provider Name (Legal Business Name): FORSYTH MEMORIAL HOSPITAL, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 07/12/2023
Certification Date: 08/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 STADIUM OAKS DR
CLEMMONS NC
27012-8962
US

IV. Provider business mailing address

PO BOX 751803
CHARLOTTE NC
28275-1803
US

V. Phone/Fax

Practice location:
  • Phone: 336-766-0547
  • Fax:
Mailing address:
  • Phone: 336-718-4820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: SHALA DAVIS
Title or Position: RCS MANAGER
Credential:
Phone: 704-303-7517