Healthcare Provider Details

I. General information

NPI: 1104124155
Provider Name (Legal Business Name): GREENSBORO FAMILY MEDICINE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2011
Last Update Date: 04/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 W NORTHWOOD ST SUITE A
GREENSBORO NC
27401-1326
US

IV. Provider business mailing address

104 W NORTHWOOD ST SUITE A
GREENSBORO NC
27401-1326
US

V. Phone/Fax

Practice location:
  • Phone: 336-790-0519
  • Fax: 336-691-8977
Mailing address:
  • Phone: 336-790-0519
  • Fax: 336-691-8977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number200600668
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number001000092
License Number StateNC

VIII. Authorized Official

Name: MR. JOHN JOSEPH DEWAR SR.
Title or Position: PHYSICIAN ASSISTANT
Credential: PA-C
Phone: 336-790-0519