Healthcare Provider Details

I. General information

NPI: 1952369571
Provider Name (Legal Business Name): ELIZABETH ROSE SCANNELL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 10/31/2023
Certification Date: 10/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1372 WESTGATE CENTER DR
WINSTON SALEM NC
27103-2932
US

IV. Provider business mailing address

PO BOX 603725
CHARLOTTE NC
28260-3725
US

V. Phone/Fax

Practice location:
  • Phone: 336-659-4814
  • Fax: 336-768-4745
Mailing address:
  • Phone: 828-575-2625
  • Fax: 828-350-2174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number200200597
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: