Provider Demographics
NPI:1083715023
Name:PIEDMONT GASTROENTEROLOGY SPECIALISTS, PA
Entity type:Organization
Organization Name:PIEDMONT GASTROENTEROLOGY SPECIALISTS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:L
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:CMPE
Authorized Official - Phone:336-714-3544
Mailing Address - Street 1:1901 S HAWTHORNE RD
Mailing Address - Street 2:SUITE 310
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-3921
Mailing Address - Country:US
Mailing Address - Phone:336-760-4340
Mailing Address - Fax:336-765-2869
Practice Address - Street 1:1901 S HAWTHORNE RD
Practice Address - Street 2:SUITE 310
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3921
Practice Address - Country:US
Practice Address - Phone:336-760-4340
Practice Address - Fax:336-765-2869
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8901548Medicaid
NC8901548Medicaid