Provider Demographics
NPI:1316935018
Name:REIDSVILLE FAMILY MEDICINE, PA
Entity type:Organization
Organization Name:REIDSVILLE FAMILY MEDICINE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:DEHART
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-634-3960
Mailing Address - Street 1:520 MAPLE AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:REIDSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27320-4652
Mailing Address - Country:US
Mailing Address - Phone:336-634-3960
Mailing Address - Fax:336-634-3919
Practice Address - Street 1:520 MAPLE AVE
Practice Address - Street 2:SUITE B
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320-4652
Practice Address - Country:US
Practice Address - Phone:336-634-3960
Practice Address - Fax:336-634-3919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-07
Last Update Date:2010-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890203MMedicaid
NC890203MMedicaid