Provider Demographics
NPI:1316303076
Name:BETHANY MEDICAL CENTER
Entity type:Organization
Organization Name:BETHANY MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:LENIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-883-0029
Mailing Address - Street 1:507 N LINDSAY ST
Mailing Address - Street 2:
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27262-4303
Mailing Address - Country:US
Mailing Address - Phone:336-883-0029
Mailing Address - Fax:336-883-0867
Practice Address - Street 1:3402 BATTLEGROUND AVE
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-2404
Practice Address - Country:US
Practice Address - Phone:336-883-0029
Practice Address - Fax:336-883-0867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-12
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC36839207N00000X
207Q00000X, 207R00000X, 363A00000X, 363L00000X
NC2013-01110207RC0000X
NC101104207RG0100X
NC103837207RG0100X
NC35265207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7901101Medicaid
NC2316178Medicaid
NC3409940Medicaid
NC89011F1Medicaid
NC5607644Medicaid
NC1619398997Medicaid
NC1780015842Medicaid
NC1992133870Medicaid
NC5607644Medicaid
NC2316178AMedicare PIN
2136178DMedicare PIN
NC1780015842Medicaid
D241Medicare PIN