Provider Demographics
NPI:1194173633
Name:LANCET RHEUMATOLOGY AND SARA LUPUS CLINIC, PLLC
Entity type:Organization
Organization Name:LANCET RHEUMATOLOGY AND SARA LUPUS CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORGANIZER AND MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:NILAMADHAB
Authorized Official - Middle Name:
Authorized Official - Last Name:MISHRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-918-3421
Mailing Address - Street 1:275 EXECUTIVE PARK BLVD STE 601
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-1548
Mailing Address - Country:US
Mailing Address - Phone:336-955-1838
Mailing Address - Fax:336-955-1842
Practice Address - Street 1:275 EXECUTIVE PARK BLVD STE 601
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103
Practice Address - Country:US
Practice Address - Phone:336-955-1838
Practice Address - Fax:336-955-1842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-25
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200000903207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89129CVMedicaid
NC129CVOtherBCBS
NCA9429OtherMEDCOST
NC89129CVMedicaid
NCA9429OtherMEDCOST