Provider Demographics
NPI:1427697978
Name:NOVANT HEALTH CLEMMONS OUTPATIENT SURGERY, LLC
Entity type:Organization
Organization Name:NOVANT HEALTH CLEMMONS OUTPATIENT SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR ASC
Authorized Official - Prefix:
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:OSBORNE
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-277-1782
Mailing Address - Street 1:101 N CHERRY ST
Mailing Address - Street 2:STE 600
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-4013
Mailing Address - Country:US
Mailing Address - Phone:336-277-1604
Mailing Address - Fax:336-277-9584
Practice Address - Street 1:7210 VILLAGE MEDICAL CIRCEL
Practice Address - Street 2:STE 235
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012
Practice Address - Country:US
Practice Address - Phone:336-893-3100
Practice Address - Fax:336-893-3109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-02
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC126701OtherAAAHC