MEDICARE: TONI WYMER, M.D. LTD

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	33772	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	33772	OTHER	NC	STATE LICENSE NUMBER

General Provider Information

NPI Number	:	1972639854
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TONI WYMER, M.D. LTD

Provider Business Mailing Address
First Line	:	201 EXECUTIVE PARK BLVD
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27103-1503
Country	:	US
Telephone Number	:	336-774-9000
Fax Number	:	336-774-9012

Provider Business Practice Location Address
First Line	:	201 EXECUTIVE PARK BLVD
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27103-1503
Country	:	US
Telephone Number	:	336-774-0920
Fax Number	:	336-774-9012

Authorized Official
Title or Position	:	ITS PRESIDENT
Name	:	DR. ANTOINETTE WYMER
Credential	:	M.D.
Telephone Number	:	336-774-0290

Provider Enumeration Date	:	02/26/2007
Last Update Date	:	03/21/2011

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