Provider Demographics
NPI:1902909328
Name:FORSYTH CARDIAC & VASCULAR SURGEONS, P.A.
Entity Type:Organization
Organization Name:FORSYTH CARDIAC & VASCULAR SURGEONS, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AR & CREDENTIALING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-794-9616
Mailing Address - Street 1:4622 COUNTRY CLUB RD
Mailing Address - Street 2:SUITE 180
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-3770
Mailing Address - Country:US
Mailing Address - Phone:336-768-9535
Mailing Address - Fax:336-768-4155
Practice Address - Street 1:4622 COUNTRY CLUB RD
Practice Address - Street 2:SUITE 180
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27104-3770
Practice Address - Country:US
Practice Address - Phone:336-768-9535
Practice Address - Fax:336-768-4155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC40490208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890127FMedicaid
NC0794Medicare PIN