Provider Demographics
NPI:1104124155
Name:GREENSBORO FAMILY MEDICINE PA
Entity type:Organization
Organization Name:GREENSBORO FAMILY MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:DEWAR
Authorized Official - Suffix:SR
Authorized Official - Credentials:PA-C
Authorized Official - Phone:336-790-0519
Mailing Address - Street 1:104 W NORTHWOOD ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-1326
Mailing Address - Country:US
Mailing Address - Phone:336-790-0519
Mailing Address - Fax:336-691-8977
Practice Address - Street 1:104 W NORTHWOOD ST
Practice Address - Street 2:SUITE A
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1326
Practice Address - Country:US
Practice Address - Phone:336-790-0519
Practice Address - Fax:336-691-8977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-28
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001000092363A00000X
NC200600668207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC87726OtherUNITED HEALTH CARE
NC142U7OtherBCBSNC
NC5907415Medicaid
TXP61329Medicare UPIN