1952579807 NPI number — CEDAR CREEK FAMILY MEDICINE PLLC

Table of content: (NPI 1952579807)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952579807 NPI number — CEDAR CREEK FAMILY MEDICINE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CEDAR CREEK FAMILY MEDICINE PLLC
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:
1952579807
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/10/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5350 S MAIN ST
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:
27107-9174
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-784-0505
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11492 OLD US HIGHWAY 52
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINSTON SALEM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27107-9497
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-784-0505
Provider Business Practice Location Address Fax Number:
336-784-0531
Provider Enumeration Date:
02/13/2008

Additional Information

Authorized Official

Authorized Official Last Name:
NIFONG
Authorized Official First Name:
KIMBERLY
Authorized Official Middle Name:
R
Authorized Official Title or Position:
CO OWNER
Authorized Official Telephone Number:
336-784-0505

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  88463 , 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: 014U9 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 89014U9 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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