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General NPI Number Information
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NPI Number | 1447370101
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Entity Type | Organization
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Legal Business Name | OLD TOWN FAMILY MEDICINE, P A
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Dates
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Enumeration Date | 03/29/2007
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Last Update Date | 01/26/2012
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Provider Practice Location Address
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Address Line | 3690 REYNOLDA RD
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City | WINSTON SALEM
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State | NC
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Zip | 27106-2230
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Country | US
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Telephone | 336-922-1363
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Fax |
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Provider Business Mailing Address
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Address Line | 3690 REYNOLDA RD
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City | WINSTON SALEM
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State | NC
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Zip | 27106-2230
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Country | US
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Telephone | 336-922-1363
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | RICHARD RAY HERBER
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Credential | MD
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Telephone | 336-922-1363
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 39614
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License Number State | NC
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