1427697978 NPI number — NOVANT HEALTH CLEMMONS OUTPATIENT SURGERY, LLC

Table of content: (NPI 1427697978)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427697978 NPI number — NOVANT HEALTH CLEMMONS OUTPATIENT SURGERY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NOVANT HEALTH CLEMMONS OUTPATIENT SURGERY, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1427697978
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/02/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 N CHERRY ST
Provider Second Line Business Mailing Address:
STE 600
Provider Business Mailing Address City Name:
WINSTON SALEM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27101-4013
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-277-1604
Provider Business Mailing Address Fax Number:
336-277-9584

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7210 VILLAGE MEDICAL CIRCEL
Provider Second Line Business Practice Location Address:
STE 235
Provider Business Practice Location Address City Name:
CLEMMONS
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27012
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-893-3100
Provider Business Practice Location Address Fax Number:
336-893-3109
Provider Enumeration Date:
01/02/2020

Additional Information

Authorized Official

Authorized Official Last Name:
GREEN
Authorized Official First Name:
GERALD
Authorized Official Middle Name:
OSBORNE
Authorized Official Title or Position:
ADMINISTRATOR ASC
Authorized Official Telephone Number:
336-277-1782

Provider Taxonomy Codes

  • Taxonomy code: 367500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 126701 . This is a "AAAHC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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