1710241716 NPI number — SHREWD SURGERY INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710241716 NPI number — SHREWD SURGERY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHREWD SURGERY INC
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:
6
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:
1710241716
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3218 PENNINGTON LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINSTON SALEM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27106-5438
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-659-9440
Provider Business Mailing Address Fax Number:
336-659-9292

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
760 HIGHLAND OAKS DR
Provider Second Line Business Practice Location Address:
STE. 200
Provider Business Practice Location Address City Name:
WINSTON SALEM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27103-7114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-659-9440
Provider Business Practice Location Address Fax Number:
336-659-9292
Provider Enumeration Date:
06/25/2012

Additional Information

Authorized Official

Authorized Official Last Name:
MARTEREE
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
336-659-9440

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  9401263 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8954191 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9401263 . This is a "LICENSE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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