Healthcare Provider Details

I. General information

NPI: 1851371066
Provider Name (Legal Business Name): FORSYTH MEMORIAL HOSPITAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 07/11/2023
Certification Date: 07/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 BROOKVIEW HILLS BLVD SUITE 204
WINSTON SALEM NC
27103-5661
US

IV. Provider business mailing address

PO BOX 751803
CHARLOTTE NC
28275-1803
US

V. Phone/Fax

Practice location:
  • Phone: 336-774-3740
  • Fax: 336-774-3780
Mailing address:
  • Phone: 336-774-3740
  • Fax: 336-774-3780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: LEEA JEANINE WALTON
Title or Position: EDI MANAGER
Credential:
Phone: 704-316-6081