Healthcare Provider Details

I. General information

NPI: 1821651548
Provider Name (Legal Business Name): ALICIA BREANN WHITEIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2019
Last Update Date: 08/01/2022
Certification Date: 08/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N ELM ST
GREENSBORO NC
27401-1004
US

IV. Provider business mailing address

14 PICCADILLY CT
DURHAM NC
27713-1875
US

V. Phone/Fax

Practice location:
  • Phone: 336-832-8064
  • Fax:
Mailing address:
  • Phone: 469-247-4654
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2022-00915
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: