Healthcare Provider Details

I. General information

NPI: 1801878632
Provider Name (Legal Business Name): SPECTRUM MEDICAL GROUP PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 04/11/2023
Certification Date: 04/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 LYNDHURST AVE
WINSTON-SALEM NC
27103-4007
US

IV. Provider business mailing address

3001 LYNDHURST AVE
WINSTON-SALEM NC
27103-4007
US

V. Phone/Fax

Practice location:
  • Phone: 336-765-0383
  • Fax: 336-760-6918
Mailing address:
  • Phone: 336-765-0383
  • Fax: 336-760-6918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: TAMMY FERRELL
Title or Position: ADMINISTRATOR
Credential:
Phone: 336-765-0383