Healthcare Provider Details

I. General information

NPI: 1477525111
Provider Name (Legal Business Name): ROBERT WILLIAM BYNUM IV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2006
Last Update Date: 05/11/2023
Certification Date: 11/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2605 FOREST HILLS RD SW STE A
WILSON NC
27893-4448
US

IV. Provider business mailing address

2605 FOREST HILLS RD SW STE A
WILSON NC
27893-4448
US

V. Phone/Fax

Practice location:
  • Phone: 252-293-9898
  • Fax: 252-293-9915
Mailing address:
  • Phone: 252-293-9898
  • Fax: 252-293-9915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number24731
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier8920580
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer
# 2
Identifier20580
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerBLUE CROSS BLUE SHEILD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: