Healthcare Provider Details

I. General information

NPI: 1518188515
Provider Name (Legal Business Name): SALEM GYNECOLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2830 MAPLEWOOD AVE SUITE B
WINSTON SALEM NC
27103-4100
US

IV. Provider business mailing address

2830 MAPLEWOOD AVE SUITE B
WINSTON SALEM NC
27103-4100
US

V. Phone/Fax

Practice location:
  • Phone: 336-794-1444
  • Fax: 336-794-1477
Mailing address:
  • Phone: 336-794-1444
  • Fax: 336-794-1477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VH0002X
TaxonomyHospice and Palliative Medicine (Obstetrics & Gynecology) Physician
License Number32358
License Number StateNC

VIII. Authorized Official

Name: MRS. TINA B CARSON
Title or Position: OFFICE MANAGER
Credential:
Phone: 336-794-1444