MEDICARE: CAROLINA MEDICORP ENTERPRISES, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	207P00000X	Emergency Medicine Physician
2	363A00000X	Physician Assistant
3	363L00000X	Nurse Practitioner
4	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710945696
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAROLINA MEDICORP ENTERPRISES, INC

Provider Business Mailing Address
First Line	:	2000 FRONTIS PLAZA BLVD STE 200
Second Line	:	(ATTN) FORSYTH MEDICAL GROUP
City	:	WINSTON SALEM
State	:	NC
Zip	:	27103-5616
Country	:	US
Telephone Number	:	336-277-2435
Fax Number	:	336-277-9275

Provider Business Practice Location Address
First Line	:	111 GATEWAY CENTER DR
Second Line	:	DBA PRIMECARE KERNERSVILLE
City	:	KERNERSVILLE
State	:	NC
Zip	:	27284-2999
Country	:	US
Telephone Number	:	336-996-2173
Fax Number	:	336-996-3254

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	PAUL M. BARRY
Credential	:	MD
Telephone Number	:	336-774-0040

Provider Enumeration Date	:	05/02/2006
Last Update Date	:	10/09/2007

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