Provider Demographics
NPI:1194060368
Name:OLDTOWN IMMEDIATE CARE, PA
Entity type:Organization
Organization Name:OLDTOWN IMMEDIATE CARE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:FRANKLIN
Authorized Official - Last Name:TRIPP
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:336-993-3146
Mailing Address - Street 1:PO BOX 30575
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27130-0575
Mailing Address - Country:US
Mailing Address - Phone:336-922-1363
Mailing Address - Fax:
Practice Address - Street 1:3690 REYNOLDA RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-2240
Practice Address - Country:US
Practice Address - Phone:336-922-1363
Practice Address - Fax:336-922-0723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-29
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC40655207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty