Healthcare Provider Details

I. General information

NPI: 1528525839
Provider Name (Legal Business Name): BETHANY MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2019
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1908 CAUDLE DR STE 105
MOUNT AIRY NC
27030-4322
US

IV. Provider business mailing address

645 N MAIN ST
HIGH POINT NC
27260-5017
US

V. Phone/Fax

Practice location:
  • Phone: 336-883-0029
  • Fax: 336-883-0867
Mailing address:
  • Phone: 369-670-8463
  • Fax: 336-899-2176

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: LENIN J PETERS
Title or Position: CEO
Credential: MD
Phone: 336-883-0029