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General NPI Number Information
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NPI Number | 1194173633
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Entity Type | Organization
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Legal Business Name | LANCET RHEUMATOLOGY AND SARA LUPUS CLINIC, PLLC
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Dates
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Enumeration Date | 05/25/2016
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Last Update Date | 07/23/2018
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Provider Practice Location Address
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Address Line | 275 EXECUTIVE PARK BLVD STE 601
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City | WINSTON SALEM
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State | NC
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Zip | 27103
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Country | US
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Telephone | 336-955-1838
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Fax | 336-955-1842
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Provider Business Mailing Address
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Address Line | 275 EXECUTIVE PARK BLVD STE 601
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City | WINSTON SALEM
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State | NC
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Zip | 27103-1548
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Country | US
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Telephone | 336-955-1838
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Fax | 336-955-1842
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Authorized Official
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Title or Position | ORGANIZER AND MEMBER
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Name | NILAMADHAB MISHRA
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Credential | MD
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Telephone | 336-918-3421
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RR0500X
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Taxonomy Name | Rheumatology Physician
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License Number | 200000903
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License Number State | NC
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