Provider Demographics
NPI:1992133870
Name:BETHANY MEDICAL CENTER
Entity type:Organization
Organization Name:BETHANY MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:WOMBLE
Authorized Official - Suffix:
Authorized Official - Credentials:
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:336-899-2188
Practice Address - Street 1:100 N BRIDGE ST
Practice Address - Street 2:SUITE C
Practice Address - City:WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28697-2488
Practice Address - Country:US
Practice Address - Phone:336-883-0029
Practice Address - Fax:336-899-2188
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BETHANY MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-10-31
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207ZC0500X, 207ZP0101X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathologyGroup - Multi-Specialty
No207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic PathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89011F1Medicaid
NC3409940Medicaid
NC5907644Medicaid
NC7901101Medicaid
NC89011F1Medicaid
NC2316178DMedicare UPIN
NC2316178Medicare UPIN
NC3409940Medicaid