Healthcare Provider Details

I. General information

NPI: 1851713374
Provider Name (Legal Business Name): WINSTON-SALEM STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2014
Last Update Date: 01/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 S MARTIN LUTHER KING JR DR A.H. RAY BLDG RM. 244
WINSTON SALEM NC
27110-0001
US

IV. Provider business mailing address

601 S MARTIN LUTHER KING JR DR A.H. RAY BLDG RM. 244
WINSTON SALEM NC
27110-0001
US

V. Phone/Fax

Practice location:
  • Phone: 336-750-3301
  • Fax: 336-750-3303
Mailing address:
  • Phone: 336-750-3301
  • Fax: 336-750-3303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANTHONY PHILADELPHIA
Title or Position: DIRECTOR
Credential: PHD.
Phone: 336-750-3274